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HX641 17600 
RC76.3  .F64  1885  A  manual  of  ausculta 


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A    MANUAL 


^  jri.^^. 


AUSCULTATION  AND  PERCUSSION. 


KMIiRACIXC;  THE 


PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  LUNGS  AND 
HEART,  AND  OF  THORACIC  ANEURISM. 


BY 

AUSTIN  FLINT,  M.D.,  LL.D., 

PB0FESSOB  OF  THE  PBIHOIPLEa    \M>    PRACTICE  "1     MIDIOINI    AHD  "I    CLINICAL  MEDICINE  IN  THI 
HK.I.I.KVI  y.  HOSPITAL  MEDICAL  COLLEGE,  ETC.,  ETC. 


FOURTH    EDITION,    THOROUGHLY   REVISED   AND    ENLARGED. 


ILLUSTRATED   WITH    FOURTEEN   WOODCUTS. 


PHILADELPHIA: 

I,  E  A     B  R  <>  T  II  E  R  s    &    C  0 
1885. 


Entered  according  to  A<  t  <••!  Congress,  in  the  year  1885,  by 

L  E  A     I!  I!  (I  T  II  E  K  S    &    C  0., 

In  the  Office  of  the  Librarian  of  Congress,  a1  Washington,  T>.  ('.    All  rights  reserved, 


DORNAN,   PRINTER. 


PREFACE  TO  THE  FOURTH  EDITION. 


The  fact  that,  within  a  little  over  two  years,  a 
large  edition  of  this  manual  has  been  exhausted,  is 
gratifying  proof  of  the  increased  favor  with  which 
it  is  regarded  by  the  medical  profession.  The 
Author  has  been  thereby  incited  to  endeavor  to 
make  it  still  more  acceptable  by  a  thorough  revision. 

The  present  edition  contains  some  important 
modifications  and  considerable  additions.  A  notable 
improvement  is  the  introduction  of  diagrammatic 
illustrations,  which  will  enhance  the  usefulness  of 
the  work. 

.\i:w  Fobs,  October,  1885. 


Figs.  1.  •_'.  :!,  and  4  arc  borrowed,  with  modifica- 
tions, from  Handbuch  and  Alias  der  topographischen 
percussion,  von  Dr.  Adolf  Weil.  Professor  an  der 
I 'nivcrsitat  Heidelberg. 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/manualofausculta1885flin 


PREFACE  TO  THE  THIRD  EDITION. 


Tx  the  revision  of  this  manual  for  a  third  edition, 
it  has  been  deemed  advisable,  as  in  the  previous 
editions,  to  restrict  its  scope  to  auscultation  and 
percussion  considered  chiefly  with  reference  to  their 
practical  application,  and  to  present  these  with  as 
much  condensation  as  possible.  In  the  present 
edition,  the  modes  by  which  pulmonary  signs  may 
be  reproduced  in  the  lungs  removed  from  the  body, 
and  by  artificial  illustrations,  have  been  briefly  stated. 
The  author  has  also  introduced  some  practical  points 
kindly  suggested  by  his  friend  and  colleague,  Pro- 
or  Janeway.  The  speedy  exhaustion  of  the 
second  edition  may.  perhaps,  be  fairly  regarded  as 
evidence,  not  alone  of  the  usefulness  of  the  work  to 
the  medical  student  and  practitioner,  bul  of  an 
increasing  appreciation  of  the  importance  of  the 
study  of  auscultation  and  percussion,  as  well  as  of 
the  analytical  method  by  which  the  study  is  facili- 
tated, and  knowledge  of  the  physical  Bigns  made 
readily  available  in  diagnosis. 

Nkw  Y'niK.  March,  L8€ 


PREFACE  TO  THE  SECOND  EDITION. 


This  work  contains  the  substance  of  the  lessons 
which  the  Author  has  for  many  years  given,  in  con- 
nection with  practical  instruction  in  auscultation 
and  percussion,  to  private  classes  composed  of 
medical  students  and  practitioners. 

In  his  courses  of  practical  instruction  his  plan  has 
been,  1st.  To  simplify  the  subject  as  much  as  pos- 
sible, avoiding  all  needless  refinements;  2d.  To 
consider  the  distinctive  characters  of  the  different 
physical  signs  as  determined,  not  by  analogies,  nor 
by  deductions  from  physics,  but  by  analysis,  and  as 
based  especially  on  variations  in  the  intensity,  pitch, 
and  quality  of  sounds ;  3d.  To  impress  the  fact  that 
the  significance  of  physical  signs  relates  to  certain 
physical  conditions,  and  the  importance  of  a  familiar 
acquaintance  with  these  conditions,  as  well  as  with 
the  distinctive  characters  of  the  signs  by  which  they 
are  represented;  Jth.  To  enforce  the  necessity  of 
sufficient  study  of  the  physical  conditions  and  the 

signs   of  health,  as   a  Sim  qua  ROfl    for   SUCC688   in  the 

study  of  the  physical  diagnosis  of  diseases;  and,  5th. 
To  waive   discussion   ^\'  the  mechanism  of  signs, 


Vlll        PREFACE    TO    THE    SECOND    EDITION. 

whenever  this  is  open  for  discussion,  taking  the 
ground  that  our  knowledge  of  the  significance  of 
signs  rests  solely  on  the  constancy  of  their  connection 
with  the  physical  conditions  which  they  represent. 

This  plan,  of  which  the  utility  has  been  confirmed 
by  continued  experience,  has  been  followed  through- 
out the  present  volume,  and  the  favor  with  which 
the  work  has  been  received  has  seemed  to  show  that 
no  radical  changes  were  required.  In  revising  it 
for  a  second  edition,  therefore,  the  Author  has  con- 
fined himself  to  such  additions  as  seemed  likely  to 
render  it  more  useful  not  only  to  students  engaged 
in  the  practical  study  of  the  subject,  but  also  to 
practitioners  as  a  handbook  for  ready  reference. 

New  York,  January,  1880. 


CONTENTS. 


CHAPTER    I . 

INTRODUCTION. 

PAGE 

Definition  of  percussion  and  auscultation— The  sounds  obtained  by 
these  methods  of  representing  healthy  and  morbid  physical  con- 
ditions—  Definition  of  signs — The  basis  of  our  knowledge  of  signs 
the  constancy  of  association  of  certain  sounds  with  certain  phy- 
sical conditions  in  health  and  disease — The  present  state  of  per- 
fection of  our  knowledge  of  signs  furnished  by  auscultation  and 
percussion — Requirements  for  the  successful  study  of  these 
methods  of  exploration — The  anatomy  and  physiology  of  the 
chest — An  enumeration  of  the  points  relating  thereto  which  are 
of  especial  importance — The  physical  conditions  incident  to  the 
different  diseases  of  the  chest:  the  conditions  relating  to  the 
respiratory  system  stated,  and  a  summary  of  them — The  dis- 
tinctive characters  of  healthy  and  morbid  signs;  variations  in 
intensity,  pitch,  and  quality,  considered  as  the  chief  source  of 
the  character-  distinguishing  the  signs  of  disease  from  each  other 
ami  from  those  of  health — Other  distinctions  than  those  of  inten- 
sity, pitch,  and  quality — The  analytical  method  of  the  study  of 
illation  and  percussion — The  significance  of  signs  as  regards 
the  physioal  condition-;  which  they  severally  represent — .Morbid 
conditions,  not  individual  diseases,  represented  by  the  morbid 
signs — Regional  divisions  of  the  chest — Anatomical  relations  of 
the  regions  severally  to  the  parts  within  the  obest,       ...      13 

c  ii  a  i'T  E  i:    ii. 

TKK'    USSIOB     IN     II  KAI.T1I. 

Percussion  with  the  lingers  or  with  a  peroussor  ami  plezi tor — 

The  normal  vesicular  resonance  on  peroussion;  it-  distinctive 
characters  relating  to  intensity,  pitch,  and  quality  —  Variation! 
in  the  characters  ot  the  Qormal  vesicular  resonanoe  m  different 


CONTENTS, 


PAGE 


persons — Relation  of  the  pitch  of  resonance  to  the  vesicular 
quality — Tympanitic  resonance  over  the  abdomen — Variations 
of  the  normal  resonance  in  the  different  regions  of  the  chest — 
Enumeration  of  the  regions  in  which  the  resonance  on  the  two 
sides  varies,  and  those  in  which  it  is  identical  in  health — In- 
fluence of  age  on  the  normal  resonance — Influence  of  the  acts 
of  respiration  on  the  resonance — Rules  in  the  practice  of  per- 
cussion,  ............ 


11 


CHAPTER    III. 

PERCUSSION    IN   DISEASE. 

Enumeration  of  the  signs  of  disease  furnished  by  percussion — 
Requirements  for  a  practical  knowledge  of  these  signs — The 
distinctive  characters  of  the  morbid  physical  conditions  repre- 
sented by,  and  the  different  diseases  into  the  diagnosis  of  which 
enter,  the  signs,  severally,  to  wit,  1.  Absence  of  resonance  or 
flatness;  2.  Diminished  resonance;  3.  Tympanitic  resonance; 
4.  Vesiculotympanitic  resonance;  5.  Amphoric  resonance:  6. 
Cracked-metal  resonance — Sense  of  resistance  felt  in  the  practice 
of  percussion,  as  a  morbid  sign,      .......       63 

CHAPTER    IV. 

AUSCULTATION    IN    HEALTH. 

Importance  of  the  study  of  the  auscultatory  sounds  in  health — Im- 
mediate and  mediate  auscultation — Advantages  of  the  binaural 
stethoscope — Rules  to  be  observed  in  auscultation — Divisions  of 
the  study  of  auscultation  in  health — The  normal  laryngeal  and 
tracheal  respiration — The  normal  vesicular  murmur;  its  distinc- 
tive characters,  and  the  variations  in  the  different  regions  on  tlie 
same  side,  and  in  corresponding  regions  on  the  two  sides  of  the 
chest — The  normal  vocal  resonance — The  laryngeal  and  tracheal 
voice  and  whisper — The  normal  thoracic  vocal  resonance  and  fre- 
mitus; the  distinctive  characters  of  each:  the  variations  in  dif- 
ferent regions  on  the  same  side,  and  in  corresponding  regions  on 
the  two  sides  of  the  chest — The  normal  bronchial  whisper,  with 
its  variations  in  different  regions  on  the  same  side,  and  in  corre- 
sponding regions  on  the  two  sides  of  the  chest,      ....       75 


CONTENTS.  XI 


('  II  A  I'T  E  R    V. 

Al'MTLTA  TION     IN     DISEASE. 

PAGE 

The  respiratory  signs  of  disease: — Abnormal  modifications  of  the 
normal  respiratory  sounds: — Increased  vesicular  murmur — Di- 
minished vesicular  murmur — Suppressed  respiratory  sound — 
Bronchial  or  tubular  respiration — Broncho-vesicular  respiration 
— Cavernous  respiration — -Broncho-cavernous  respiration — Vesic- 
ulo-cavernous  respiration — Amphoric  respiration — Shoitened  in- 
spiration— Prolonged  expiration — Interrupted  respiration.  Ad- 
ventitious respiratory  sounds  or  rales.  Laryngeal  or  tracheal 
rules — Moist  bronchial  rales,  coarse,  fine,  and  Buborepitant — 
•ular  or  crepitant  rale — Cavernous  or  gurgling  rale — Pleural 
friction  rales,  metallic  tinkling  and  splashing — Indeterminate 
rales.  The  vocal  signs  of  disease:  Bronchophony — Whispering 
bronchophony  —  JSgophony  —  Increased  vocal  resonance — In- 
creased bronchial  whisper — Cavernous  whisper — Pectoriloquy — 
Amphoric  voice  or  echo — Diminished  anil  suppressed  vocal  reso- 
nance— Diminished  and  suppressed  vocal  fremitus — Metallic 
tinkling.     Signs  obtained  by  acts  of  coughing  or  tussive  sounds,  .       98 


C  11  A  PT  E  R    VI. 

Till:    PHYSICAL    DIAGNOSIS    "I     DISEASES    OJ    THE    RESPIRATORY 
ORGANS. 

Affections  "f  the  larynx  and  trachea— Bronchitis  seated  in 
bronchial  tubes — Bronchitit  seated  in  small  bronchial  tubes,  or 
capillary  bronchitis— Collapse  of  pulmonary  lobules — Lobular 
pneumonia  -Asthma — Pulmonary  or  resioular  emphysema  — 
Pleurisy,  acute  and  ohronio  Empyema  Hydrothorax  Pneu- 
mothorax —  Pneumohydrothorax  —  Pneumo-pyothorax  —  Acute 
lobar  pneumonia  Circumscribed  pneumonia  —  Embolic  pneu- 
monia Hemorrhagic  infarotui  -Pulmonarj  apoplexy— Pulmo- 
nary gangrene  Pnlmonarj  Carcinoma  of  lung  Tumor 
within  the  oh  est  —  Aoute  miliary  tuberoulosii  -Pulmonary  phthisis 
— Fibroid  phthisis,  interstitial  pneumonia,  or  oirrhosii  <>i  lung — 
Diaphragmatic  hernia,  .........     154 


XU  CONTENTS, 


CHAPTER    VII. 

THE    PHYSICAL    CONDITIONS    OF    THE    HEART    IN    HEALTH    AND 
DISEASE.       THE  HEART-SOUNDS  AND  CARDIAC  MURMURS. 

PAGE 

Physical  conditions  of  the  heart  in  health  :  Boundaries  of  the 
prsecordia — Normal  situation  of  the  apex-heat — Boundaries  of 
the  deep  and  of  the  superficial  cardiac  space — Relations  of  the 
aorta  and  the  pulmonary  artery  to  the  walls  of  the  chest — The 
heart-sounds — Characters  distinguishing  the  first  and  the  second 
sound — Mechanism  of  the  production  of  the  heart-sounds — Aus- 
cultation of  the  pulmonic  and  the  aortic  second  sound  separately 
— Auscultation  of  the  mitral  and  tricuspid  valvular  sounds  — 
Movements  of  the  auricles  and  ventricles  in  relation  to  each 
other — Physical  conditions  of  the  heart  in  disease:  Enlarge- 
ment of  the  heart — Hypertrophy  and  dilatation — Abnormal  im- 
pulses of  the  heart,  and  modifications  of  the  apex-beat — Valvular 
lesions — Roughness  of  the  pericardial  surfaces — Liquid  within 
the  pericardial  sac — Abnormal  modifications  of  the  heart-sounds 
— Reduplication  of  heart-sounds — Cardiac  murmurs — Normal  and 
abnormal  blood-currents  within  the  heart,  and  their  relations 
with  the  heart-sounds — Mitral  direct  murmur — Mitral  regurgi- 
tant murmur — Mitral  systolic  non-regurgitant,  or  intra-ventric- 
ular  murmur — Mitral  diastolic  murmur — Aortic  direct  murmur — 
Aortic  regurgitant  murmur,  and  an  Aortic  diastolic  non-regurgi- 
tant murmur — Coexisting  endocardial  murmurs— Tricuspid  direct 
murmur  —  Tricuspid  regurgitant  murmur  —  Pulmonic  direct 
murmur — Pulmonic  regurgitant  murmur — Facts  of  practical  im- 
portance in  relation  to  endocardial  murmurs — Pericardial  or  fric- 
tion murmur,  ............     20:? 

C  II  AFTER    V  1  1  I . 

THE    PHYSICAL    DIAGNOSIS    OF    DISEASES    OF    THE    HEART    AND    OF 
THORACIC    ANEURISM. 

Enlargement  of  the  heart  by  hypertrophy  and  dilatation — Valvular 
lesions,  mitral,  aortic,  tricuspid,  and  pulmonic — Fatty  degenera- 
tion and  softening  of  the  heart — Endocarditis — Pericarditis — 
Functional  disorders — -Thoracic  aneurism,      .....     250 


MANUAL 

OF 

AUSCULTATION  AND  PERCUSSION. 


CHAPTER  I. 

INTRODUCTION. 

Definition  of  percussion  and  auscultation — The  sounds  obtained  by  these 
methods  of  representing  healthy  and  morbid  physical  conditions — 
Definition  of  signs — The  busis  of  our  knowledge  of  signs  the  constancy 
of  association  of  certain  sounds  with  certain  physical  conditions  in 
health  and  disease — The  present  state  of  perfection  of  our  knowledge 
of  signs  furnished  by  auscultation  and  percussion — llequirements  for 
the  successful  study  of -these  methods  of  exploration — The  anatomy 
and  physiology  of  the  chest — An  enumeration  of  the  points  relating 
thereto  which  are  of  especial  importance — The  physical  conditions  in- 
cident to  the  different  diseases  of  the  chest:  the  conditions  relating 
to  the  respiratory  system  stated,  and  a  summary  of  them — The  dis- 
tinctive characters  of  healthy  and  morbid  signs ;  variations  in  inten- 
sity, pitch,  ami  quality,  tonsidered  as  the  chief  source  of  the  character 
distinguishing  the  signs  of  disease  from  each  other  and  from  those  of 
health — Other  distinctions  than  those  of  intensity,  pitch,  and  quality — 
The   analytical    method    of  the   study  of  auscultation    and  percussion  — 

The  Bignifloanoe  of  signs  as  regards  the  physical  condition-  which  they 
severally  represent— Morbid  conditions,  not  individual  diseases,  repre- 
sented by  the  morbid  si^ns-  Regional  divisions  of  the  ohest— Ana- 
tomioal  relations  of  the  regions  severally  to  the  parts  within  the  chest. 

Physical  Exploration. 

'I'm-;  physical  exploration  of  the  chesl  embraces  Bis 
different  methods,  namely  :  auscultation,  percussion, 
inspection,  palpation,  mensuration,  and  Buccussion. 
Of  these,  auscultation  and  percussion,  dealing  with 


14  INTRODUCTION. 

sounds,  involve  the  sense  of  hearing.  In  percussion, 
the  sounds  are  produced  by  striking  upon  the  walls 
of  the  chest;  in  auscultation,  they  are  caused  by 
acts  of  breathing,  speaking,  and  coughing. 

The  sounds  in  auscultation  and  percussion  are, 
1st,  normal  or  healthy  sounds,  being  produced 
when  there  is  no  disease  of  the  chest;  and,  2d,  ab- 
normal or  morbid  sounds,  being  produced  when  the 
chest  is  the  seat  of  disease.  The  sounds,  healthy 
and  morbid,  constitute  what  are  known  as  physical 
signs.  Frequently,  for  the  sake  of  brevity,  the  term 
signs,  without  the  word  physical,  is  used  to  denote 
these  sounds.  Conventionally,  physical  signs,  or 
signs,  are  terms  employed  in  a  sense  of  contradis- 
tinction to  the  term  symptoms.  The  signs  are  dis- 
tinguished, of  course,  as  normal  or  healthy,  and 
abnormal  or  morbid. 

The  sounds  which  constitute- signs  represent  cer- 
tain physical  conditions  pertaining  to  the  chest. 
The  normal  or  healthy  signs  represent  physical  con- 
ditions existing  when  the  organs  are  not  affected  by 
disease ;  the  abnormal  or  morbid  signs  represent 
physical  conditions  which  are  deviations  from  those 
of  health,  being  incident  to  the  various  diseases  of 
the  chest.  The  physical  conditions  represented  by 
signs  may  be  distinguished  as  normal  or  healthy, 
and  abnormal  or  morbid  conditions. 

The  representation  of  healthy  and  morbid  physical 
conditions  by  certain  healthy  and  morbid  signs  is 
established  by  having  ascertained  a  constancy  of 
association  of  the  signs  with  the  conditions.  This 
constancy  of  association  is  ascertained  by  observa- 
tion or  experience.     The  sounds  obtained  by  per- 


PHYSICAL    EXPLORATION.  15 

cussion  and  auscultation  in  health  are  thereby 
established  signs  of  healthy  conditions,  and  the 
sounds  obtained  only  in  cases  of  disease  are  thereby 
established  signs  of  morbid  conditions.  Our  knowl- 
edge of  certain  Bounds  as  the  signs  of  certain  phy- 
sical conditions  can  have  no  reliable  basis  other 
than  the  constancy  of  the  connection  of  the  former 
with  the  latter.  This  constancy  of  connection  is 
determined  by  the  study  of  the  sounds  during  life 
and  examination  of  the  organs  after  death.  The 
existence  of  certain  conditions  is  not  to  be  inferred 
from  the  characters  of  certain  sounds  until  the  con- 
nection of  the  sounds  with  the  conditions  has  been 
ascertained  by  experience;  then,  and  then  only,  are 
the  sounds  to  be  reckoned  as  signs  of  these  condi- 
tions. So,  also,  it  is  not  to  be  interred  from  certain 
physical  conditions  found  after  death,  that  certain 
sounds  must  have  been  produced  during  life,  until 
the  connection  between  the  conditions  and  the 
sounds  has  been  ascertained  by  experience.  In 
other  words,  our  knowledge  of  signs  as  represent- 
ing physical  conditions,  can  rest  on  no  other  than  a 
purely  empirical  foundation. 

Our  knowledge  of  tic  signs  representing  the  phy- 
sical conditions  in  health  and  disease,  thanks  to  the 
labors  Of  Laennec,  and   of  those  who   have  followed 

in  his  footsteps,  has  been  brought  to  great  perfec- 
tion. The  practical  object  of  this  knowledge  is  to 
determine  by  means  of  auscultation  and  percussion, 
together  with  the  other  methods  of  exploration,  the 
iteuce  of  either  healthy  or  morbid  physical  condi- 
tions, and  to  discriminate  the  latter  from  each  other; 
that  is  to  say,  the  practical  objeel  is  diagnosis.     The 


16  INTRODUCTION. 

signs  now  known  to  represent  physical  conditions, 
healthy  and  morbid,  taken  in  connection  with  symp- 
toms and  pathological  laws,  render,  for  the  most  part, 
the  diagnosis  of  diseases  of  the  chest  easy  and  posi- 
tive. Hence,  it  becomes  the  duty  of  the  medical 
student  and  practitioner  to  give  to  auscultation  and 
percussion  attention  sufficient,  at  least,  for  their 
practical  application  to  the  diagnosis  of  the  diseases 
commonly  met  with  in  medical  practice;  and  this 
duty  is  the  more  imperative  because  it  involves 
neither  peculiar  difficulties  nor  great  labor.  In 
entering  upon  the  undertaking  it  is  important  to 
consider  the  requirements  for  the  successful  study 
of  this  province  of  practical  medicine.  These 
requirements  relate  to :  1st,  the  anatomy  and  phy- 
siology of  the  chest;  2d,  the  morbid  physical  con- 
ditions incident  to  the  different  diseases  of  the  chest; 
3d,  the  distinctive  character  of  healthy  and  morbid 
signs;  and,  4th,  the  significance  of  the  signs  as  re- 
gards the  physical  conditions  which  they  severally 
represent. 

Anatomy  and  Physiology  of  the  Respiratory  Organs. 

The  necessity  of  a  knowledge  of  the  anatomy  and 
physiology  of  the  chest,  as  a  requirement  for  the 
study  of  auscultation  and  percussion,  together  with 
the  other  methods  of  physical  exploration,  is  too 
obvious  to  need  any  discussion.  The  physical  con- 
ditions of  health  must  be  known  as  preparatory  for 
appreciating  the  physical  conditions  of  disease.  It 
would  be  absurd  to  think  of  studying  the  latter  until 
the  former  are  known.  The  student,  therefore,  who 
is  not  acquainted  with  the  anatomy  and  physiology 


ANATOMY    AND    PHYSIOLOGY    OF    CHEST.      17 

of  the  chest,  must  defer  entering  upon  the  study  of 
physical  diagnosis  until  this  requirement  is  fulfilled. 
Familiarity  with  the  morbid  physical  conditions  is 
necessary ;  and  for  the  advanced  medical  student  or 
the  practitioner  it  is  advisable  to  refresh  the  memory 
with  a  reviewal  of  certain  anatomical  and  physio- 
logical points  before  beginning  the  study  of  auscul- 
tation and  percussion.  These  points,  relating  espe- 
cially to  the  physical  conditions  of  health,  cannot  be 
considered  in  this  work.  A  simple  enumeration  of 
them  can  only  be  introduced,  the  reader  being  re- 
ferred f,,r  details  to  treatises  on  anatomy  and  phy- 
siology. 

Important    anatomical    conditions    relate   to   the 
bones  of  the  chest,  namely,  the  general   conforma- 
tion of  the  thorax  ;  the  differences  in  respect  of  the 
obliquity  of  the  ribs  from    above    downward;    the 
direction  of  the   costal   cartilages,   their  connection 
with   the   sternum,  and    the   angles  formed  by  the 
junction  of  the  ribs  and  cartilages;  the  differences 
in    width   of  the  intercostal    spaces    in    the    upper, 
middle,  and  lower  portions  of  the  anterior,  lateral, 
and   posterior  aspects  of  the  thorax,  together  with 
the  relations  of  the  scapula  and  clavicle.      The   rela- 
tive thickness  of  the  muscular  covering  of  the  chest 
in  different  situations  is  to  lie  considered,  and,  in 
women,  the  varying  size   of  the   mamma'.      The  at- 
tachments <»f  the  diaphragm  t<>  the  thoracic  walls, 
and   its   relations  to    the    organs   below,  as   well    as 
above  it,  are  points  of  importance.     Figs.  1,2,8,  I. 
Important   physiological  conditions   relate  to  the 
parts  which  the  ribs,  costal  cartilages,  sternum,  and 
diaphragm  severally  play  in  the  movements  ofrespi 


18  INTRODUCTION. 

ration.  The  differences,  in  respect  of  these  move- 
ments, in  tranquil  and  in  forced  breathing.  The 
contrast  between  the  two  sexes,  and  between  early 
and  advanced  life,  are  points  to  be  studied.  Other 
points  are,  the  frequency  of  the  respirations  in 
health,  and  the  relative  duration,  rapidity,  and 
force  of  the  inspiratory  and  the  expiratory  move- 
ments. 

Certain  anatomical  and  physiological  points  per- 
tain to  the  organs  within  the  chest.  The  more 
important  of  these,  relating  to  normal  physical  con- 
ditions, are  the  following:  1st,  as  regards  the  lungs, 
the  connections  of  the  pleura,  and  the  smoothness 
of  the  pleural  surfaces  in  contact  with  each  other; 
the  relations  of  the  apex  and  base  of  each  lung  to 
the  chest-walls,  and  the  differences  of  the  two  lungs 
in  this  respect;  the  relative  spaces  occupied  respec- 
tively by  the  two  lobes  of  the  left,  and  the  three 
lobes  of  the  right  lung ;  the  situation  of  the  inter- 
lobar fissures  in  either  side  on  the  posterior,  lateral, 
and  anterior  aspects  of  the  chest;  the  arrangement 
of  the  air-vesicles,  pulmonary  lobules,  and  the  dif- 
ferent-sized intra-pulmonary  bronchial  tubes;  the 
expansion  of  the  air-vesicles,  and  the  movement  of 
the  current  of  air  from  larger  to  smaller  bronchial 
tubes  in  the  act  of  inspiration,  the  vesicles  diminish- 
ing in  size,  and  the  current  of  air  moving  from 
smaller  to  larger  tubes  in  the  act  of  expiration;  the 
difference  in  respect  of  the  relative  proportion  of  air 
and  solids  at  the  end  of  inspiration  and  at  the  end 
of  expiration ;  the  extent  to  which  the  volume  of 
the  lungs  may  be  diminished  by  a  forced  act  of  ex- 
piration, and  increased  by  a  forced  act  of  inspira- 


ANATOMY    AND    PHYSIOLOGY    OF    CHEST.       10 

tion ;  the  relations  of  the  apices  to  the  subclavian 
arteries,  and  the  variable  extent  to  which  the  apex 
rises  on  either  side  above  the  clavicle.  2d,  as  re- 
gards the  larynx,  trachea,  and  the  bronchial  tubes 
without  the  lungs,  the  anatomy  and  physiology  of 
the  vocal  chords,  of  the  muscles  concerned  in  the 
movements  of  respiration  and  of  phonation,  with 
the  relations  of  each  to  the  recurrent  laryngeal 
nerve,  the  size  of  the  rima  glottidis  in  youth,  after 
puberty,  and  relatively  in  the  two  sexes,  the  enlarge- 
ment of  the  rima  in  the  act  of  inspiration,  the  dimi- 
nution of  its  size  in  the  act  of  expiration,  and  the 
closer  approximation  of  the  chords  in  the  act  of 
coughing ;  the  difference  in  the  amount  of  areolar 
tissue  above  the  vocal  chords  in  children  and  in 
adults;  the  situation  of  the  trachea,  and  the  point 
of  its  bifurcation;  the  length,  direction,  and  size  of 
the  two  primary  bronchi  contrasted  with  each  other, 
and  the  branches  which  penetrate  the  lungs.  3d,  as 
regards  the  heart,  the  boundaries  of  the  space  which 
it  occupies — thai  is,  of  the  precordial  space;  the 
relation  of  the  aorta  and  pulmonic  artery  to  the 
walls  of  the  chest;  the  portions  of  the  precordial 
space  in  which  the  heart  is  covered  and  uncovered 
by  lung;  the  situations  of  the  auricles  and  ven- 
tricles respectively;  the  relations  of  these  to  each 
other,  and  the  arrangements  of  the  valves:  the 
currents  of  blood  through  the  orifices  within  the 
heart,  and  the  relations  of  each  of  these  to  the  beart- 
BOunds;  the  rhythmical  succession  of  these  sounds: 
the  differences  which  distinguish  each  from  the  other 
in  respect  of  loudness,  duration,  tone,  quality,  extent 
of  diffusion,  and  the  situation  in  which  each  has  its 


20  INTRODUCTION. 

maximum  of  intensity ;  the  mechanism  of  these 
sounds,  and  the  situation  of  the  apex-beat.  Figs.  1, 
2,  3,  4. 

The  foregoing  are  the  anatomical  and  physio- 
logical points  which  especially  claim  attention  with 
reference  to  normal  physical  conditions,  preparatory 
to  entering  on  the  study  of  abnormal  physical  con- 
ditions represented  by  the  signs  furnished  by  auscul- 
tation and  percussion  together  with  the  other  methods 
of  physical  exploration. 

It  is  recommended  to  the  student,  before  pro- 
ceeding further,  either  to  acquire  or  review  knowl- 
edge respecting  all  these  points.  Knowledge  of 
these  should  be  made  familiar,  if  it  be  not  already 
so,  by  reference  to  works  treating  of  the  anatomy 
and  physiology  of  the  chest. 

The  Morbid  Physical  Conditions  Incident  to  the  Different 
Diseases  of  the  Respiratory  System. 

The  various  morbid  physical  conditions  incident 
to  different  diseases  must  be  known,  for  it  is  the 
immediate  object  of  auscultation,  percussion,  and 
the  other  methods  of  exploration,  to  ascertain  either 
the  existence  or  the  absence  of  these  morbid  con- 
ditions. Knowledge  of  all  the  important  conditions 
which  are  deviations  from  those  of  health,  and  the 
relations  of  each  to  different  diseases,  is,  therefore, 
an  essential  requirement. 

Deviations  from  the  normal  conformation  of  the 
chest  and  the  various  abnormal  movements  of  respi- 
ration, belong  properly  among  the  physical  signs 
obtained  by  inspection,  palpation,  and  mensuration. 
For  the  most  part,  these   signs   represent  morbid 


DISEASES    OF    RESPIRATORY    SYSTEM.        21 

physical  conditions  within  the  chest.  Certain  con- 
ditions relate  to  the  presence  of  liquid,  either  serous, 
sero-fibrinous,  or  purulent,  within  the  pleural  sac. 
The  quantity  of  liquid  may  be  large  enough  to  com- 
press the  lung  into  a  solid  mass,  and  to  enlarge  the 
affected  side,  at  the  same  time  restraining  or  annul- 
ling the  respiratory  movements ;  the  chest  on  the 
affected  side,  then,  will  contain  only  lung  solidified 
by  compression,  and  liquid.  In  other  cases  the 
quantity  of  liquid  is  either  small,  moderate,  or  con- 
siderable, the  lung  then  containing  a  lessened 
quantity  of  air,  and  its  volume  diminished  in  pro- 
portion to  the  amount  of  liquid.  These  morbid 
conditions  are  incident  to  simple  pleurisy  with 
effusion,  pyothorax  or  empyema,  and  hydrothorax. 

The  pleural  surfaces,  in  cases  of  pleurisy,  may  be 
more  or  less  covered  with  recent  fibrinous  exuda- 
tion, and,  when  not  separated  by  the  presence  of 
liquid,  they  do  not  move  upon  each  other  smoothly 
and  noiselessly.  The  friction  of  the  opposed  sur- 
faces is  si  ill  more  productive  of  audible  and  some- 
times tactile  signs  after  the  absorption  of  liquid, 
when  the  exudation  has  become  more  adherent  and 
dense  than  when  it  is  recent. 

The  presence  of  air  in  the  pleural  space,  either 
alone  or  with  more  or  less  liquid,  in  pneumothorax, 
may  compress  the  lung  into  a  solid  mass,  also  dilat- 
ing the  affected  side,  and  restraining  ov  annulling 
its  movements:  and  the  air,  with  or  without  liquid, 
when  not  in  sufficienl  quantity  to  produce  tl: 
effects,  may  diminish  more  or  less  the  volume  of  the 
lung  and  the  aiimum  of  air  in  the  pulmonary  vesicles. 

These  morbid  conditions  give  rise  to  characteristic 


22  INTRODUCTION. 

physical  signs.  The  perforation  of  lung,  usually 
existing  in  cases  of  pneumothorax,  occasions  addi- 
tional signs  which  are  characteristic. 

Solidification  of  lung  is  an  important  physical 
condition  incident  to  several  diseases,  irrespective 
of  the  condensation,  just  referrred  to,  caused  by  the 
compression  of  liquid  or  air  in  the  pleural  sac. 
Complete  consolidation  of  an  entire  lobe,  or  of  two 
and  even  three  lobes,  exists  in  the  second  stage  of 
lobar  pneumonia.  Certain  physical  signs  represent 
this  condition  of  complete  solidification.  The  dif- 
ferent degrees  of  solidification,  namely,  slight,  mod- 
crate,  and  considerable,  occur  during  the  stage  of 
resolution  in  cases  of  pneumonia,  and  these  gra- 
dations are  severally  represented  by  well-defined 
characters  pertaining  to  physical  signs.  Solidifica- 
tion, circumscribed,  forming  nodules  which  vary  in 
size  and  number,  situated  in  the  upper,  lower,  or 
middle  portion  of  the  lung,  either  on  one  side  or  on 
both  sides,  exists  in  phthisis,  in  broncho-pneumonia 
and  collapse  of  pulmonary  lobules,  in  hydatids,  in 
hemorrhagic  infarctus  and  embolic  pneumonia,  in 
pulmonary  gangrene,  and  in  carcinoma.  It  exists, 
greater  or  less  in  degree  and  more  or  less  extended, 
in  interstitial  pneumonia.  In  these  different  con- 
nections the  existence  of  solidification,  its  degree 
and  extent,  its  limitation  to  one  situation  or  its  ex- 
istence at  different  points,  are  determinable  by  means 
of  physical  signs. 

A  morbid  condition  the  opposite  of  solidification 
is  an  abnormal  accumulation  of  air  within  the  air- 
vesicles  of  the  lungs.  This  is  incident  to  pulmonary 
or  vesicular  emphysema,  involving  a  morbid  dilata- 


DISEASES    OF    RESPIRATORY    SYSTEM.        23 

tion  of  the  air-vesicles.  The  permanent  expansion 
and  increased  vol  nine  of  the  upper  lobes  in  some 
cases  of  this  disease,  occasion  a  characteristic  de- 
formity of  the  chest,  together  with  certain  devia- 
tions from  the  normal  movements  of  respiration, 
which  are  also  characteristic.  This  morbid  condi- 
tion is  represented  by  distinctive  signs  furnished  by 
auscultation  and  percussion.  The  extravasation  of 
air  in  the  connective  tissue,  constituting  interlobular 
and  subpleural  emphysema,  in  like  manner  gives  rise 
to  signs  furnished  by  these  methods  of  exploration. 

The  presence  of  a  viscid  exudation  within  the  air- 
vesicles  and  bronchioles,  is  a  morbid  physical  condi- 
tion incident  to  acute  pneumonia,  especially  in  its 
first  stage,  agglutinating  the  cells  and  bronchioles, 
the  walls  of  which  may  be  brought  into  contact  or 
close  proximity  at  the  end  of  the  act  of  expiration. 
The  separation  of  the  walls  thus  agglutinated,  in 
the  act  of  inspiration,  gives  rise  to  an  auscultatory 
sign  (the  crepitant  rale)  which  is  pathognomonic  of 
that  disease. 

An  accumulation  of  serum  within  the  air-vesicles 
constitutes  the  condition  called  pulmonary  oedema. 
This  condition  gives  rise  to  signs  furnished  by  aus- 
cultation and  percussion. 

Liquid  within  the  bronchial  tubes  (serum,  pus, 
blood,  or  thin  mucus')  is  a  condition  incident  to  pul- 
monary oedema,  abscess  either  of  the  lung  or  situated 

elsewhere  and  evacuating  through  the  bronchial 
tubes,  phthisis,  bronchorrhagia,  pneumorrhagia, 
bronchorrhcea,  and  bronchitis.  The  passage  of  air 
through  the  different  varieties  of  liquid  in  the  tubes 
cause-   bubbling    sounds   which    are    appreciable   in 


24  INTRODUCTION. 

auscultation.  The  apparent  size  of  the  bubbles 
(coarseness  or  fineness)  denotes  the  size  of  the  tubes 
in  which  they  are  [trod need,  and  the  pitch  of  the 
bubbling  sounds  denotes  either  solidification  or 
otherwise  of  the  pulmonary  substance  surrounding 
the  tubes  in  which  the  bubbles  are  produced.  Bub- 
bling sounds  more  intense  and  on  a  larger  scale  are 
caused  by  the  presence  of  liquid  within  the  trachea 
and  larynx,  known  as  the  tracheal  rales  or  the  death 
rattle. 

Diminished  calibre  of  the  bronchial  tubes  within 
the  lungs,  either  localized  or  diffused,  is  a  condition 
due  to  the  presence  of  tenacious  mucus,  and  the 
swelling  of  the  mucous  membrane  in  cases  of  bron- 
chitis. In  cases  of  so-called  capillary  bronchitis 
the  condition  may  involve  an  alarming  degree  of 
obstruction.  The  same  morbid  condition  is  inci- 
dent to  bronchial  spasm  in  asthma,  occasioning  in 
this  disease  great  suffering,  but  without  immediate 
danger.  The  condition  is  represented  by  ausculta- 
tory signs  which  enable  the  auscultator  to  differ- 
entiate the  obstruction  due  to  capillary  bronchitis 
from  that  due  to  bronchial  spasm.  Permanent  ob- 
literation of  more  or  less  of  the  bronchial  tubes  is 
an  occasional  morbid  condition. 

Obstruction  of  a  bronchial  tube,  either  within  or 
without  the  lung,  is  a  morbid  condition  involving 
the  loss  of  respiratory  sound  within  the  area  of  the 
bronchial  branches  and  vesicles  not  receiving  air  in 
consequence  of  the  obstruction.  The  obstruction 
may  be  temporary,  being  caused  bj7  a  plug  of  mucus 
of  sufficient  size  to  prevent  the  passage  of  air;  the 
morbid   condition    is   then    incident   to    bronchitis. 


DISEASES    OF    RESPIRATORY    SYSTEM.        25 

One  of  the  primary  bronchi  may  be  obstructed 
temporarily  by  a  plug  of  mucus,  and  obstruction  of 
the  larynx  in  childhood  thus  produced  may  be  suffi- 
cient to  cause  death  by  suffocation.  The  inhalation 
of  foreign  bodies  is  another  cause  of  obstruction 
within  the  larynx,  trachea,  or  bronchi.  A  primary 
bronchus  or  the  trachea  may  be  pressed  upon  by  an 
aneurisnial  or  other  tumor,  and,  in  this  way,  more 
or  less  obstruction  to  the  passage  of  air  is  produced. 
However  produced,  the  situation  of  the  obstruction 
and  its  degree  are,  in  general,  determinable  by 
means  of  auscultatory  signs. 

Dilatation  of  bronchial  tubes  occasions  two  morbid 
physical  conditions  differing  as  regards  their  auscul- 
tatory signs,  namely,  1st,  an  enlargement  of  greater 
or  less  extent,  the  tubes  preserving  their  cylindrical 
form  :  and,  2d,  a  sacculated  enlargement.  The 
former  occurs  generally  in  connection.with  solidifi- 
cation around  the  tubes  from  hyperplasia  of  the 
areolar  tissue,  and  is  thus  incident  to  interstitial 
pneumonia.  The  latter  may  give  rise  to  signs 
which  represent  pulmonary  cavities. 

Sacculated  dilatations  of  bronchial  tubes,  and  the 
cavities  incident  to  phthisis,  pulmonary  abscess  and 

circumscribed  gangrene  of  lung,  are  represented  by 
well-marked  and  highly  distinctive  signs  furnished 
by  auscultation  and  percussion.  The  signs  denote 
either  thai  cavities  have  flaccid  walls  which  collapse 
in  expiration  and  expand  in  inspiration,  or  that, 
owing  to  solidification  of  lung,  they  remain  open 
during  both  acts  of  respiration. 

More  or  less  of  the  space  within  the  chest  which, 
normally,  is  occupied   by  lung,  may  be  encroached 

8 


26  INTRODUCTION. 

upon  by  aneurisms  or  other  intra-thoracic  tumors. 
This  is  a  physical  condition  giving  rise  to  notable 
morbid  signs  furnished  by  auscultation  and  per- 
cussion. 

Finally,  an  extremely  rare  morbid  physical  con- 
dition is  the  presence  of  more  or  less  of  the  hollow 
viscera  of  the  abdomen  within  the  chest,  in  conse- 
quence of  either  a  congenital  deficiency  in  the 
diaphragm,  or  a  wound  penetrating  this  muscle 
(diaphragmatic  hernia). 

The  foregoing  morbid  physical  conditions  relate 
to  the  respiratory  organs.  Those  relating  to  the 
heart  are  deferred  in  order  that  they  may  precede 
more  immediately  an  account  of  the  signs  of  cardiac 
disease.  As  a  requirement  for  the  study  of  morbid 
physical  signs,  the  foregoing  morbid  physical  condi- 
tions must  be  understood  and  memorized.  To 
assist  the  student  in  the  latter,  a  summary  of  these 
conditions  is  appended. 

Summary  of  Morbid  Physical  Conditions  Incident  to 
Diseases  of  the  Respiratory  Organs.    , 

1.  An  accumulation  of  serous,  sero-fibrinous,  or 
purulent  liquid  sufficient  to  fill  the  affected  side  of 
the  chest,  and  sometimes  causing  more  or  less  en- 
largement. 

2.  An  accumulation  of  liquid  partially  filling  the 
affected  side  of  the  chest,  the  quantity  being  either 
small,  moderate,  or  considerable. 

3.  Fibrinous  exudation  on  the  pleural  surface. 

4.  Air  with  liquid  within  the  pleural  cavity,  and 
perforation  of  lung. 


HEALTHY    AND    MORBID    SIGNS.  27 

5.  Air  without  liquid  in  the  pleural  cavity. 

6.  Solidification  of  lung,  either  complete  or  ap- 
proximating to  completeness. 

7.  Solidification  of  lung,  slight  or  moderate  in 
degree. 

8.  Dilatation  of  the  air-vesicles,  involving  within 
them  an  abnormal  accumulation  of  air. 

'.».  Extravasation  of  air  within  the  pulmonary 
connective  structure 

10.  Exudation  within  air-vesicles  and  bronchioles. 

11.  Liquid  within  air-vesicles. 

12.  Liquid  (mucus,  serum,  pus,  or  blood)  within 
bronchial  tubes  of  large,  medium,  or  small  size. 

1"..  Liquid  within  bronchial  tubes  of  minute  size. 

14.  Obstruction  of  the  pulmonary  bronchial  tubes 
by  mucus,  swelling  of  the  mucous  membrane,  and 
spasm  of  the  bronchial  muscular  fibres. 

15.  Obstruction  of  larynx,  trachea,  or  bronchi 
exterior  to  the  lungs,  by  plugs  of  mucus  or  foreign 
bodies. 

16.  Obstruction  of  the  trachea  or  a  primary  bron- 
chus by  aneurismal  or  other  tumors. 

17.  Dilatation  of  bronchial  tubes,  cylindrical  or 
sacculated. 

1 s.   Pulmonary  cavities. 
L9.  Tumor  within  the  chest. 
20.  Diaphragmatic  hernia. 

The  Distinctive  Characters  of  Healthy  and  Morbid  Signs. 
For  the  practice  of  auscultation  and  percussion  it 

is  essential  tO  be  able  to  recognize  the  signs,  sever- 
ally, which  represent  the  differenl  physical  condi- 
tions in   health   ami  disease.      It    is  essential    to  dis- 


28  INTRODUCTION. 

tinguish  the  morbid  from  the  healthy  signs,  and  to 
discriminate  from  each  other,  severally,  the  signs 
of  disease.  The  recognition  and  discrimination 
of  signs  require  a  knowledge  of  the  distinctive 
characters  belonging  to  each  of  them.  In  entering 
upon  the  study  of  the  signs,  therefore,  it  is  a  neces- 
sary requirement  to  know  whence  their  distinctive 
characters  are  derived.  To  this  point  of  inquiry  the 
attention  of  the  student  is  now  invited. 

The  signs  being  sounds,  they  are  to  be  recognized 
and  discriminated  in  the  way  in  which  we  practically 
recognize  and  discriminate  other  sounds.  It  is  not 
necessary,  in  order  to  do  this,  to  study  the  science 
of  acoustics.  In  becoming  familiar  with  other 
sounds,  for  example,  musical  notes  produced  by 
different  instruments,  or  the  varieties  of  the  human 
voice,  we  do  not  have  recourse  to  that  science.  It 
suffices  for  all  practical  purposes  to  contrast  the 
sounds  obtained  by  auscultation  and  percussion  with 
reference  to  very  simple  and  obvious  differences; 
and,  yet,  it  is  necessary  to  understand  very  clearly 
in  what  these  differences  consist,  or,  in  other  words, 
the  sources  of  the  distinctive  characters  of  these 
sounds.  The  more  important  of  the  differences  be- 
tween the  sounds  obtained  by  auscultation  and  per- 
cussion relate  to  intensity,  pitch,  and  quality.  The 
distinctive  characters  of  most  of  the  signs  are  derived 
from  these  three  sources.  In  becoming  practically 
acquainted  with  the  signs,  they  are  to  be  contrasted 
as  regards  intensity,  pitch,  and  quality,  precisely  as 
we  would  bring  other  sounds  into  contrast  in  these 
three  aspects.  The  distinctive  characters  of  the 
signs,  severally,  are  especially  derived  from  their 


HEALTHY    AND    MORBID    SIGNS.  29 

differences  in  these  respects.  The  distinctions  ex- 
pressed by  the  terms  intensity,  pitch,  and  quality, 
are,  therefore,  to  be  made  clear. 

Differences  in  the  intensity  of  sounds  are  easily 
understood.  One  sound  is  more  intense  than  another 
sound  when  it  is  simply  louder,  and  varying  degrees 
of  intensity  are  expressed  by  such  terms  as  feeble  or 
weak  and  loud,  to  which  may  be  prefixed  adjectives 
of  quantity,  such  as  very,  moderate,  etc.  This  is  all 
that  need  be  said  with  reference  to  the  first  of  the 
three  aspects  under  which  sounds  are  contrasted. 
It  will  be  seen  hereafter  that  intensity  is  an  essential 
element  in  the  distinctive  characters  of  certain  of 
the  signs. 

Differences  in  the  pitch  of  sounds  are  easily  un- 
derstood by  those  who  have  given  any  attention  to 
music.  The  differences  are  expressed  by  the  terms 
bigh  and  low,  to  which  may  be  prefixed  words  de- 
noting a  greater  or  less  degree  of  highness  or  low- 
ness.  A  nice  appreciation  of  variations  in  the  pitch 
of  musical  notes,  requires  what  is  known  as  a  "mu- 
Bical  ear;"  but  a  very  nice  appreciation  is  not 
essential  in  comparing,  as  regards  pitch,  the  soun<l> 
studied  in  auscultation  and  percussion.  For  the 
CQOSl  part,  these  sounds  are  not  musical  notes; 
nevertheless,  differences  in  pitch  are  readily  per- 
ceived. A  musical  ear  is  undoubtedly  an  advantage 
in  readily  distinguishing  differences  in  pitch:  hut  ii 
is  by  n<>  means  a  sine  >/>/'/  rum.     For  those  who  have 

given  no  attention   to  music,  some  difficulty  niav  DO 

at  first  experienced  in  judging  correctly  of  differ- 
ences in  this  regard:  hut  die  difficulty  disappears 
alter  a   little   practice.     Differences   in   pitch  now 

3* 


30  INTRODUCTION. 

enter  pretty  largely  into  the  distinctive  characters 
of  physical  signs;  but  by  Laennec,  and  those  who  im- 
mediately followed  him,  comparatively  little  atten- 
tion was  paid  to  the  study  of  signs  with  reference  to 
these  differences.  The  writer  was  led  to  engage  in 
this  study  more  than  a  quarter  of  a  century  ago, 
and  hereafter,  in  giving  an  account  of  the  different 
signs,  he  will  claim  to  have  been  the  first  to  have 
clearly  indicated  certain  characters  from  this  source.1 
Differences  relating  to  quality  are  apt,  at  first,  to 
be  confounded  with  those  relating  to  pitch  ;  hence 
the  distinction  between  pitch  and  quality  must  be 
clearly  understood.  We  may  say  of  the  quality  of 
a  sound,  that  it  embraces  whatever  is  not  embraced 
in  the  terms  intensity  and  pitch.  This  is  true  as  a 
general  statement.  The  sense  of  the  term  quality, 
in  distinction  from  intensity  and  pitch,  may  be  most 
readily  made  clear  by  an  illustration.  Let  it  be  sup- 
posed that  we  hear  the  notes  of  an  instrument  which 
is  unseen — the  performer,  for  example,  being  in  an- 
other room.  We  recognize  at  once  the  instrument 
by  the  notes,  provided  it  be  one  with  which  Ave  are 
familiar,  such  as  a  violin,  a  flute,  a  clarionet,  etc. 
We  do  not  need  to  see  the  instrument;  we  recognize 
it  by  the  sounds.  Now,  how  do  we  recognize  it  ? 
Certainly  not  by  the  intensity  of  the  sounds;  it 
matters  not  whether  these  be  loud  or  weak,  so  that 
we  hear  them.  Certainly  not  by  the  pitch ;  for  if  a 
piece  of  music  be  performed,  we  get  both  high  and  low 
notes.     We  recognize  the  instrument  by  the  quality 

1  Vide  Prize  Essay  on  "Variations  <>f  Pitch  in  Percussion  and 
Respiratory  Sounds,  and  their  Application  to  Physical  Diagnosis." 

Transactions  of  the  American  Medical  Association,  1852. 


HEALTHY    AND     IffOKBID    SIGNS.  31 

of  the  sounds.  Each  musical  instrument,  owing 
to  its  peculiarity  of  construction,  yields  sounds 
which  are  peculiar  to  it ;  and  after  we  have  become 
familiar  with  the  quality  of  sounds  peculiar  to  an 
instrument,  we  immediately  thereby  recognize  it. 
Precisely  in  the  same  way  we  may  recognize  certain 
sounds  produced  by  auscultation  and  percussion  in 
health  and  disease.  The  signs  differ  in  quality  ac- 
cording to  the  physical  conditions  which  they  sever- 
ally represent;  and  differences  in  quality  will  he 
found  hereafter  to  constitute  essential  and  obvious 
distinctions  by  which  the  Bigns  of  health  and  disease 
are  recognized  and  discriminated.  This  is  a  source 
of  some  of  the  most  distinctive  of  the  characters  of 
certain  of  the  physical  signs. 

<  >f  the  peculiar  quality  of  any  particular  sound 
one  ean  form  no  definite  idea  otherwise  than  by 
direct  observation.  That  is  to  say,  no  one  could 
describe  to  another  the  peculiar  quality  of  a  par- 
ticular sound  so  that  it  would  be  clearly  appre- 
hended without  the  sound  having  been  heard. 
Imagine  tin-  attempt  to  describe  the  sound  of  a 
violin  to  a  person  who  had  never  listened  to  the 
notes  from  that  instrument — it  would  he  impossible 
to  give  a  correct  idea  of  it  in  language.  The  only 
way  in  which  an  approximate  idea  could  be  con- 
veyed in  words,  would  be  by  comparing  the  quality 
to  that  of  some  other  instrument  to  the  notes  of 
which  there  was  some  resemblance — that  is,  by 
analogy.     'I'd   attempt    to   describe   tin-   quality  of 

sounds   to   one    who    had    never    heard    them,    would 

he  like  describing  colors  to  one  blind.  It  will  be 
Been  hereafter  that   the  quality  of  en-tain  Bounds 


32  INTRODUCTION. 

obtained  by  auscultation  aud  percussion  is  peculiar 
to  them,  and  their  distinctive  characters  in  this 
respect  can  be  known  only  by  direct  observation  ; 
they  cannot  be  learned  by  means  of  any  verbal 
description,  nor  by  any  comparisons — that  is,  by 
analogy. 

Appreciable  variations  in  the  quality  of  sounds 
are  infinite.  This  may  be  illustrated  by  the  human 
voice.  Almost  every  person  may  be  recognized  from 
a  peculiar  quality  of  the  voice  by  one  who  is  familiar 
with  it;  and  the  voices  of  thousands  of  persons,  if 
compared,  would  present  shades  of  difference — in 
fact,  as  is  well  known,  it  is  extremely  rare  for  the 
voices  of  any  two  persons  to  be  so  nearly  identical 
ill  quality  that  they  cannot  be  distinguished  from 
each  other.  As  the  diversity  in  quality  of  different 
sounds  cannot  be  described,  so  they  can  only  be 
designated  by  names  which  are  significant  from 
certain  resemblances.  Terms  based  on  analogies 
which  are  used  to  denote  qualities  of  the  sounds 
furnished  by  auscultation  and  percussion  are  the 
following:  rough,  harsh,  and  rude,  soft,  blowing, 
hollow,  musical,  moist,  dry,  bubbling,  gurgling, 
crackling,  clicking,  rubbing,  grating,  creaking,  tu- 
bular, cracked  metal,  sibilant  or  whistling,  sonorous 
or  snoring.  All  these  names  owe  their  significance 
to  resemblances  to  other  sounds.  One  sound  fur- 
nished both  by  auscultation  and  percussion  has  a 
quality  which  is  sui  generis,  and  the  term  used  to 
distinguish  it  is  derived  from  its  source,  namely,  the 
vesicular  resonance,  and  the  vesicular  murmur  of 
respiration. 


HEALTHY    AND    MORBID    SIGNS.  33 

Iii  addition  to  intensity,  pitch,  and  quality,  as 
sources  of  the  distinctive  characters  of  the  signs 
furnished  by  auscultation  and  percussion,  there  are 
some  other  points  of  difference,  namely,  the  duration 
of  certain  sounds,  their  continuousness  or  otherwise, 
their  apparent  nearness  to,  or  distance  from,  the  ear, 
their  rhythmical  succession,  and  their  strong-  resem- 
blance to  particular  sounds,  such  as  the  bleating  of 
the  goat,  the  chirping  of  birds,  etc.  These  points  of 
difference  are  important,  although  less  so  than  those 
relating  to  intensity,  pitch,  and  quality. 

The  study  of  the  different  sounds  furnished  by 
auscultation  and  percussion,  with  reference  to  dis- 
tinctive characters  relating  especially  to  intensity, 
pitch,  and  quality,  distinct  signs  being  determined 
from  points  of  difference  as  regards  these  characters, 
may  be  distinguished  as  the  analytical  method.  It 
may  be  so  distinguished  in  contrast  with  the  deter- 
mination of  signs  deductively,  taking  as  a  stand- 
point cither  the  physical  conditions  incident  to 
diseases  or  the  sounds.  If  we  undertake  to  decide, 
h  "priori,  that  certain  sounds  must  be  furnished  by 
auscultation  and  percussion  when  certain  conditions 
are  present,  we  shall  be  led  into  error;  and  so, 
equally,  if  we  undertake  to  conclude  from  the  nature 
of  the  sounds  that  they  must  represent  certain  con- 
ditions. The  only  reliable  method  is  to  analyze  the 
Bounde  with  reference  to  differences  relating  espe- 
cially to  intensity,  pitch,  and  quality,  and  to  de- 
termine different  signs  by  these  differences,  the 
import  of  each  of  the  Bigns  being  then  established 
by  the  constancy  of  association  with  physical  condi- 


34  INTRODUCTION. 

tions.  It  is  by  this  analytical  method  only  that  the 
distinctive  characters  of  signs  can  be  accurately  and 
clearly  ascertained.  This  is  to  be  borne  in  mind  by 
the  student  in  physical  exploration.  He  is  to  be- 
come acquainted  with  the  different  signs,  and  to 
recognize  them  in  practice,  by  acquiring  a  knowl- 
edge of  the  distinctive  characters  of  each,  as  derived 
mainly  from  differences  relating  to  intensity,  pitch, 
and  quality.  The  individualitj-  of  the  signs,  sever- 
ally, can  rest  on  no  other  solid  basis. 

The  Significance  of  the  Signs  as  regards  the  Physical 
Conditions  which  they  severally  represent. 

Knowledge  of  the  significance  of  the  physical 
signs  is  the  complemental  requirement  in  the  study 
of  auscultation  and  percussion.  For  the  successful 
employment  of  these  methods,  in  addition  to  the 
recognition  of  each  sign  by  its  distinctive  characters, 
must  be  known  its  significance,  that  is,  the  physical 
condition  which  it  represents.  In  this  respect  the 
signs  may  be  compared  to  the  substantives  in  lan- 
guage, each  having  a  definite  meaning.  The  signs 
furnished  by  these  methods  may  be  said  to  consti- 
tute a  language  with  a  very  small  vocabulary ;  or, 
taking  as  the  standpoint  the  things  signified,  the 
different  physical  conditions  are  expressed  by  means 
of  the  signs. 

It  is  to  be  noted  that  the  significance  of  the  morbid 
signs  relates  immediately,  not  to  diseases,  but  to  the 
physical  conditions  incident  thereto.  Very  few  signs 
are  directly  diagnostic  of  any  particular  disease. 
They  represent  conditions  not  peculiar  to  one,  but 
common  to   several,  diseases.     Thus,  solidification 


REGIONAL    DIVISIONS    OF    THE    CHEST.       35 

of  lung  exists  in  pneumonia,  phthisis,  pleurisy  with 
effusion,  collapse,  and  pulmonary  cancer;  now, 
certain  signs  tell  us  that  this  morbid  condition 
exists,  together  "with  its  situation,  its  degree,  and  its 
extent.  With  this  information  the  diagnosis  of  the 
disease  is  made  by  connecting  with  it  pathological 
laws,  together  with  the  history  and  symptoms.  The 
student  in  physical  exploration  should  by  no  means 
imagine  that,  for  the  diagnosis  of  diseases,  exclusive 
reliance  is  to  be  placed  on  the  signs;  they  are  always 
to  be  taken  in  connection  with  pathological  laws,  the 
history,  and  the  symptoms.  Disconnected  from  these, 
the  signs  would  often  lead  to  error,  and  it  is  no  dis- 
paragement to  physical  diagnosis  that  its  reliability 
depends  on  other  tacts  than  those  which  belong  ex- 
clusively to  it. 

To  repeat  a  statement  already  made  more  than 
once,  the  significance  of  the  signs,  as  regards  the 
conditions  which  they  severally  represent,  is  based 
on  the  constancy  of  their  association  with  the  latter. 
our  knowledge  of  this  association  being  derived  from 
examinations  during  life  and  after  death. 

Regional  Divisions  of  the  Chest. 

Before  entering  on  the  study  of  physical  explora- 
tion, the  student  should  become  acquainted  with 
the  divisions  of  the  surfaces  of  the  anterior,  pos- 
terior, and  lateral  aspects  of  the  chest  into  circum- 
scribed spaces  which  are  called  regions.  These 
divisions,  deriving  their  boundaries  and  names 
from  their  anatomical  relations,  are  sufficiently 
simple. 

Anteriorly  the  chesl   is  divided   into  regions  as 


36 


INTRODUCTION. 


follows :    The  supra-  or  post-clavicular  region    ex- 
tends from  the  clavicle  upward   a  short  distance, 


Fig.  l. 


The  horizontal  lines  indicate  the  boundaries  of  the  regional  divisions  on  the  an- 
terior aspect  of  the  chest.  The  vertical  line  is  the  linea  mamillaris.  The  oblique 
dotted  lines  indicate  the  interlobar  fissures. 

ab,  ac,  ed,  and  bd,  boundaries  of  superficial  cardiac  space.    </..  outer  boundary  of 

deep  cardiac  space;  ce,  lower  boundary  of  right  lung;  df,  lower  boundary  of  left 

lung  ;  fjh,  upper  boundary  of  right  and  left  lung;  fen,  lower  boundary  of  hepatic  fiat- 

pg,  upper  boundary  of  hepatic  dulness;  no,  lower  boundary  of  the  stomach 

moderately  distended. 


REGIONAL    DIVISIONS    OF    THE    CHEST.       37 

corresponding  to  the  variable  height  to  which  the 
lung  rises  above  this  bone.     The  clavicular  region 


The  longitudinal  and  vertical  line*  Indicate  the  regional  diTudona  on  the  posterior 

i  the  ctteei 
ab,  lower  boondarj  of  lungs;  <•./,  lower  limil  f,  Interlobar 

k,  F-i > l •  ■•- 1 1  ;  I,  lower  bonndarj  ofliTer;  h,  lefl  kJdnej  ;  '.  right  kidney. 

embraces  the  Bpace  occupied  by  the  clavicle.     The 
infra-clavicular  region  embraces  the  space  between 

i 


38 


INTRODUCTION, 


the  clavicle  and  the  third  rib.  The  mammary 
region  is  bounded  above  by  the  third  and  below 
by  the  sixth  rib,  and  the  infra-mammary  region  is 
the  portion  of  the  chest  below  the  sixth  rib. 


Fig.  3. 


The  horizontal  line  indicates  the  regional  division  of  the  lateral  aspect  of  the  chest. 
ab,  lower  boundary  of  right  lung  ;  al,  lower  boundary  of  hepatic  flatness  ;  if,  upper 
boundary  of  hepatic  dulness ;  g,  border  of  kidney. 


REGIONAL    DIVISIONS    OF    THE    CHEST.       39 

Posteriorly  the  divisions   are  into  the  scapular, 
the  infra-scapular,  and  inter-scapular  regions.     The 


Fig.  4. 


"'■,  bonndarj  "t  hepatic  flatness;  <■'.  lower  boundary  of  lefl  long;  a,  ft  :/,  h,i,).,i, 

bonndarioa  •■!   spleen;  bn,  boundary  of  Udo  lower  I adariea  ..i   the 

rtonuu  li  in  different  degree*  <•!  distention. 

Bcapular  region  is  the  space  occupied  by  the  Bcapula, 
and  is  divided  by  the  spinous  ridge  into  the  upper 


40  INTRODUCTION. 

and  lower  scapular  space.  The  infra-scapular  region 
is  the  portion  below  a  horizontal  line  intersecting 
the  lower  angle  of  the  scapula.  The  inter-scapular 
region  is  the  space  between  the  posterior  margin  of 
the  scapula  and  the  spinal  column. 

Laterally  there  are  two  regions,  namely,  the  ax- 
illary and  the  infra-axillary.  The  axillary  region  is 
the  space  above  a  horizontal  line  extending  from 
the  lower  border  of  the  mammary  region,  i.  e.,  the 
sixth  rib.  The  infra-axillary  region  is  the  portion 
below  the  axillary  region. 

The  portion  of  the  anterior  surface  occupied  by 
the  sternum  is  divided  into  the  upper  and  the  lower 
sternal  region,  the  space  above  the  sternal  notch 
being  the  supra-sternal  region. 

In  order  to  become  familiar  with  the  foregoing 
regional  divisions,  it  is  recommended  to  the  student 
to  delineate  them  with  ink  on  the  chest  of  the  living 
subject  or  a  cadaver.     Figs.  1,  2,  3,  4. 

It  is  advisable  to  study  sections,  extending  from 
the  surface  to  the  centre  of  the  chest,  corresponding 
to  the  different  regions,  so  as  to  become  familiar 
with  the  relation  of  each  section  to  the  parts  con- 
tained within  it.  An  enumeration  of  the  more  im- 
portant of  the  anatomical  relations  of  the  different 
regions  is  as  follows  : 

1.  Supra- clavicular  Region. — This  is  relative  to  the 
upper  extremity  or  apex  of  the  lung,  which  rises 
above  the  clavicle  in  different  persons  from  half  an 
inch  to  an  inch  and  a  half.  The  height  is  generally 
greater  on  one  side,  and  this  side  is  usually  the  left. 

2.  Clavicular  Region. — A  small  portion  of  the  lung 


REGIONAL    DIVISIONS    OF    THE    CHEST.       41 

at  or  near  the  apex  is  contained  in  the  section  cor- 
responding to  this  region. 

3.  Infra-clavicular  Region.  —  The  parts  situated 
here,  exclusive  of  the  upper  sternal  region  (vide 
No.  7),  are  the  upper  portion  of  the  lung,  and  the 
extra-pulmonary  bronchi.  The  differences  between 
the  two  primary  bronchi,  as  regards  direction,  size, 
and  length,  are  important  points  in  the  study  of  this 
section. 

4.  Mammary  Region. — The  differences  between 
the  two  sides  in  the  sections  corresponding  to  this 
region  are  important.  These  differences  relate  es- 
pecially to  the  prrecordia,  and  are  involved  in  the 
physical  diagnosis  of  enlargement  of  the  heart. 
The  commencement  of  the  interlobular  fissures  is 
in  this  region.  On  the  left  side  the  fissure  is 
between  the  fourth  and  fifth  ribs.  On  the  right 
side  the  fissure  between  the  upper  and  middle  lobes 
begins  at  the  fourth  costal  cartilage,  and  between 
the  middle  and  lower  lobes  a  short  distance  below. 
The  situations  of  the  fissures,  however,  differ  con- 
siderably during  the  acts  of  inspiration  and  expi- 
ration. 

5.  Infrarmammary  Begum. — This  region  differs  in 
its  anatomical  relations  considerably  on  the  two 
sides  of  the  chest.  On  the  right  side  the  liver 
pushes  upward  the  diaphragm  nearly  or  quite  to 
tin-  upper  boundary,  namely,  the  sixth  rib.  On  the 
left  side  the  section  corresponding  to  the  region 
embraces,  together  with  the  anterior  portion  of  the 
lower  lobe  of  the  lung,  portions  of  the  stomach, 
Bpleen,  and  the  left  lobe  of  the  liver.  The  variable 
volume  of  the  stomach  al  differenl  times  occasions 

i* 


42  INTRODUCTION 

considerable  variations  in  the  relative  spaces  occu- 
pied by  these  different  parts. 

6.  Supra-sternal  Region. — This  region  is  in  relation 
to  the  trachea. 

7.  The  Upper  Sternal  Region. — The  bifurcation  of 
the  trachea  is  beneath  the  sternum  at  the  centre  of 
a  line  connecting  the  second  ribs.  Below  this  line 
the  lungs  on  the  two  sides  are  nearly  in  contact  at 
the  mesial  line,  covering  the  primary  bronchi. 

8.  Lower  Sternal  Region. — The  sternum  in  this  re- 
gion covers  a  large  portion  of  the  right  and  a  little 
of  the  left  ventricle. 

9.  Scapular  Region. — The  sections  corresponding 
to  this  region  contain  the  posterior  portion  of  the 
upper  lobe  and  a  portion  of  the  upper  part  of  the 
lower  lobe  of  the  lung.  At  the  upper  part  of  the 
lower  scapular  space  terminates  the  fissure  separat- 
ing the  upper  and  the  lower  lobe.  The  line  of  this 
fissure  pursues  an  oblique  course  to  the  fourth  or 
fifth  rib  on  the  anterior  aspect  of  the  chest. 

10.  Infra-scapular  Region. — On  the  right  side  the 
lung  extends  from  the  upper  boundary  of  this  re- 
gion to  the  eleventh  rib,  the  liver  rising  to  the  latter 
point.  On  the  left  side  the  section  contains  a  por- 
tion of  the  spleen. 

11.  Inter-scapular  Region. — The  trachea  extends  in 
this  section  to  the  fourth  dorsal  vertebra,  where  it 
bifurcates.  Below  this  point,  on  the  two  sides,  are 
situated  the  primary  bronchi. 

12.  Axillary  Region. — The  section  corresponding 
to  this  region  contains  a  portion  of  the  upper  lobe 
with  large  bronchial  tubes. 


REGIONAL    DIVISIONS    OF    THE    CHEST.       43 

13.  Infra-axillary  Region. — This  is  in  relation  to 
the  upper  part  of  the  liver  on  the  right  side,  and  on 
the  left  side  to  a  portion  of  the  spleen  and  stomach, 
the  remainder  of  the  section  occupied  by  lung. 

It  is  recommended  to  the  student  to  become  fami- 
liar with  the  sections  corresponding  to  the  different 
regions,  by  dissections  for  this  purpose,  and  the 
study  of  anatomical  illustrations.     Figs.  1,  2,  3,  4. 

Asking  the  student's  careful  attention  to  the  in- 
troductory considerations  which  have  been  pre- 
sented, auscultation  and  percussion  in  health  and 
disease,  and  the  physical  signs  involved  in  the  diag- 
nosis of  diseases  of  the  respiratory  system  and  of  the 
heart,  will  be  considered  as  follows :  Chapter  II., 
Percussion  in  Health;  Chapter  III.,  Percussion  in 
Disease;  Chapter  IV.,  Auscultation  in  Health; 
Chapter  V".,  Auscultation  in  Disease;  Chapter  VI., 
The  Physical  Diagnosis  of  the  Diseases  of  the  Respi- 
ratory System  ;  Chapter  VII.,  The  Physical  Condi- 
tions of  the  Heart  in  Health  and  Disease;  Chapter 
VIII.,  The  Physical  Diagnosis  of  Diseases  of  the 
Heart;  and,  as  properly  embraced  in  the  scope  of 
this  treatise,  Chapter  IX.  will  be  devoted  to  the 
Diagnosis  of  Thoracic  Aneurism-. 


CHAPTER  II. 

PEKCUSSION  IN  HEALTH. 

Percussion  with  the  fingers  or  with  a  percussor  and  pleximeter — The 
normal  vesicular  resonance  on  percussion;  its  distinctive  characters 
relating  to  intensity,  pitch,  and  quality — Variations  in  the  characters 
of  the  normal  vesicular  resonance  in  different  persons — Relation  of  the 
])itch  of  resonance  to  the  vesicular  quality- — Tympanitic  resonance  over 
the  abdomen — Variations  of  the  normal  resonance  in  the  different  re- 
gions of  the  chest— Enumeration  of  the  regions  in  which  the  resonance 
on  the  two  sides  varies,  and  those  in  which  it  is  identical  in  health — 
Influence  of  age  on  the  normal  resonance — Influence  of  the  acts  of 
respiration  on  the  resonance — Rules  in  the  practice  of  percussion. 

Percussion  may  be  performed  with  either  the 
lingers  or  artificial  instruments.  The  fingers  suffice 
for  the  study  and  in  ordinary  practice.  Instruments 
are  preferable  only  when  it  is  desired  to  produce 
sounds  to  be  heard  at  a  distance,  as  in  class  illustra- 
tions, and  when,  from  the  number  of  patients  to  be 
percussed,  as  in  dispensary  or  hospital  practice,  the 
frequent  repetition  of  the  blows  renders  the  fingers 
tender  and  painful.  The  instruments  are  a  plexi- 
meter and  a  percussor.  A  simple  and  convenient 
pleximeter  is  an  oval  disk  of  ivory  or  hard  India- 
rubber,  with  projecting  handles  or  auricles  suffi- 
ciently large  and  roughened  on  their  outer  aspect 
so  as  to  be  conveniently  held  by  the  fingers.  The 
author  has  lately  used  with  satisfaction  a  plexi- 
meter consisting  of  a  piece  of  hard  rubber  bent  up- 
ward at  one  extremity,  and    ending   in  a  handle. 


NORMAL    RESONANCE.  45 

(Fig.  6.)  The  best  percussor  is  a  double  cone  of 
caoutchouc  encircled  at  its  centre  with  a  handle  of 
convenient  length  and  size,  the  ring  and  the  handle 
made  of  vulcanized  rubber.  The  instrument  is  very 
durable.     (Fig.  7.) 

Fig.  5. 


Rubber  Pleximeter. 


When  percussion  is  performed  with  the  fingers, 
the  palmar  surface  of  one  or  more  of  those  of  the 
left   hand    should   be    applied   to   the   chest,   with 


Fig.  G. 


pressure  sufficient  to  condense  the  soft  structures, 
and  the  blows  are  given  with  one  or  more  of  the 
lingers  of  the  right  hand  bent  at  the  second  phalan- 


Fio.  7. 


. 


geal  joint  so  as  to  form  a  righl  angle    In  giving  the 
blows,  the  movements  should  be  limited  to  the  wrist- 


46  PERCUSSION    IN    HEALTH. 

joint,  the  ends,  not  the  pulp,  of  the  percussing  fingers 
being  brought  into  contact  with  the  dorsal  surface  of 
the  finger  or  fingers  applied  to  the  chest.  The  per- 
cussing fingers  should  be  withdrawn  instantly  the 
blow  is  given.  The  type  of  perfect  percussion  is 
the  movement  of  the  hammers  when  the  keys  of  a 
piano-forte  are  struck.  The  force  of  the  percussion 
should  never  be  sufficient  to  give  pain  to  the  pa- 
tient; generally  either  light  or  moderately  forcible 
blows  suffice.  The  requisite  tact  in  the  perform- 
ance of  percussion  is  acquired  by  a  little  practice. 

The  first  object  in  the  study  of  percussion  is  to 
become  acquainted  with  the  characters  which  are 
distinctive  of  the  sound  obtained  thereby  from  the 
healthy  chest.  For  this  object  the  percussion  may 
be  made  either  in  the  infra-clavicular  region  of 
either  side,  or  in  the  infra-scapular  region,  the 
sound  in  these  situations  being  louder  than  in  other 
regions.  Percussion  being  performed,  a  sound  or 
resonance  is  produced.  This  sound  or  resonance  is 
now  to  be  analyzed  with  reference  to  characters  de- 
rived from  intensity,  pitch,  and  quality.  What  are 
these  characters  ?  The  intensity  will  depend,  other 
things  being  equal,  on  the  force  of  the  blow;  the 
resonance  is  comparatively  feeble  with  a  slight,  and 
loud  with  a  strong,  percussion.  Other  circum- 
stances affect  the  intensity,  irrespective  of  the  force 
of  the  blow,  namely,  the  volume  of  the  lung,  the 
elasticity  of  the  costal  cartilages,  and  the  thickness 
of  the  soft  parts  which  cover  the  chest.  Owing  to 
these  circumstances,  the  intensity  of  the  resonance 
is  by  no  means  similar,  in  the  same  situation,  in  all 
healthy  persons;  it  is  comparatively  feeble  in  some 


NORMAL    RESONANCE.  47 

and  loud  in  others.  There  is  nothing  distinctive  of 
this  normal  resonance  to  be  derived  from  intensity, 
and  we  say,  therefore,  that  the  intensity  is  variable. 

What  is  the  pitch  of  this  normal  resonance  ?  The 
pitch  of  a  sound  is  always  relative;  and,  comparing 
this  resonance  with  all  the  morbid  signs  obtained 
by  percussion,  it  is  lower  in  pitch.  "We  say,  there- 
fore, that  the  pitch  of  this  normal  resonance  is  low. 
The  pitch,  however,  is  found  to  vary  in  different 
healthy  persons. 

What  is  the  quality  of  this  normal  resonance?  It 
has  a  quality  which  is  peculiar  to  it.  In  this  respect 
it  is  not  identical  with  any  sound  produced  other- 
wise than  by  percussion  over  healthy  lung  either 
within  or  without  the  chest.  The  quality  cannot, 
therefore,  be  Learned  by  analogy,  nor  can  it  be  de- 
scribed; it  can  only  be  appreciated  by  direct  obser- 
vation. The  peculiar  quality  is  due  to  the  fact  that 
thr  resonance  is  from  air  contained  in  the  pulmonary 
ve.-icles.  This  arrangement  causes  the  peculiar 
quality,  just  as  the  construction  of  any  particular 
musical  instrument  causes  the  quality  of  tone  pecu- 
liar to  that  instrument;  hence,  as  it  is  convenient 
to  give  the  quality  a  name,  we  call  it  the  vesicular 
quality.  This  quality  ie  not  equally  marked  in  all 
healthy  persons,  being  as  a  rule  more  marked  in 
proportion  to  the  intensity  of  the  resonance. 

This  vesicular  quality,  as  just  noted,  is  peculiar  to 
the  pulmonary  resonance.  An  approximative  repre- 
sentation of  it  is  obtained  by  percussing  either  a 
sponge  or  a  loaf  of  bread.  The  latter  gives  a  closer 
imitation  than  the  former.  Each  of  these  articles 
affords  a  resemblance  to  the  vesicular  quality  of  n 


48  PERCUSSION    IN    HEALTH. 

nance,  for  the  reason  that  it  contains  air  in  an 
infinite  number  of  small  spaces,  in  this  regard  re- 
sembling the  lungs.  In  order  to  represent  this  sign 
by  percussing  a  loaf  of  bread,  the  loaf  should  be 
covered  with  a  napkin,  in  order  to  lessen  the  noise 
produced  by  the  contact  of  the  finger  or  the  percus- 
sor,  and  thus  to  elicit  better  resonance  from  the  air 
contained  in  the  interstices  of  the  loaf.  The  upper 
crust  stands  in  place  of  the  thoracic  wall.  The 
resonance  elicited  illustrates  the  lowness  of  pitch 
with  a  pretty  close  approach  to  the  peculiar  quality 
of  the  normal  vesicular  resonance. 

The  normal  resonance,  then,  obtained  by  percus- 
sion, may  be  thus  defined  : 

A  resonance  of  variable  intensity,  low  in  pitch 
and  having  a  peculiar  quality  called  vesicular.  The 
word  vesicular  is  frequently  embraced  in  the  name 
of  this  healthy  sign ;  it  is  also  called  the  normal 
resonance,  the  normal  pulmonary  resonance,  or  the 
normal  vesicular  resonance.  The  last  of  these  names 
is  to  be  preferred. 

The  normal  vesicular  resonance  on  percussion,  as 
has  been  seen,  is  not  uniform  in  all  healthy  persons; 
not  only  is  its  intensity  variable,  but  it  varies  in 
pitch  and  in  the  amount  of  vesicular  quality.  This 
may  be  easily  illustrated  by  percussing  successively 
in  the  same  situation,  and  with  the  same  force,  a 
series  of  persons  who  are  assumed  to  be  free  from 
disease.  Is  there  not  in  this  fact  an  obstacle  in 
practically  determining  this  healthy  sign  ?  The 
fact  occasions  no  embarrassment  for  this  reason : 
we  determine,  in  each  case,  that  the  resonance  is 
normal  by  a  comparison   of  the  two  sides  of  the 


VARIATIONS    IN    NORMAL    RESONANCE.      49 

chest,  percussing  in  corresponding  situations  on  the 
two  sides  and  with  the  same  force.  There  is  no 
ideal  standard  of  the  normal  vesicular  resonance, 
but,  by  comparing  the  two  sides  of  the  chest,  the 
standard  of  health  proper  to  each  person  is  obtained. 
The  laws  of  disease  are  such  that,  for  all  practical 
purposes,  the  standard  of  health  is  in  this  way  almost 
always  available.  Notwithstanding  the  variations 
within  the  range  of  health,  the  lowness  in  pitch  and 
the  vesicular  quality  are  sufficiently  distinctive  of 
this  normal  sign  as  compared  with  the  morbid  signs. 

The  pitch  of  the  vesicular  resonance  and  its  vesic- 
ular quality  arc  in  a  uniform  relation  to  each  other; 
that  is.  the  conditions  giving  rise  to  the  peculiar 
quality  also  render  the  pitch  low.  In  proportion 
as  the  vesicular  quality  is  marked,  the  pitch  is 
lowered,  and,  conversely,  with  diminution  of  the 
vesicular  quality  the  pitch  is  relatively  higher.  This 
relation  between  the  pitch  and  quality  will  be  found 
to  hold  good  in  the  resonance  modified  by  disease 
as  well  as  in  health.  Another  relation  may  be  here 
stated,  namely,  whenever,  in  health  or  disease,  a 
tympanitic  quality  is  combined  with  the  vesicular, 
and  in  proportion  as  the  former  predominates,  the 
pitch  of  the  resonance  is  raised. 

The  pitch  and  quality  of  the  normal  vesicular 
resonance  may  be  readily  illustrated  by  percussing 
successively  over  the  chest  and  the  abdomen.  The 
different  sections  of  the  alimentary  canal  generally 
containing  more  or  less  gas,  a  resonance  is  obtained 
by  percussion  over  the  abdomen.  This  resonance 
is.  of  course,  devoid  of  the  vesicular  quality  ;  in  con- 
tradistinction to  the  latter,  its  quality  is  called  tym- 


50  PERCUSSION    IN    HEALTH. 

panitic.  This  tympanitic  resonance  is  not  uniform 
in  all  parts  of  the  abdomen,  but  everywhere  the 
quality  is  tympanitic,  that  is,  non-vesicular,  and  the 
pitch  is  everywhere  higher  than  that  of  the  normal 
vesicular  resonance.  The  tympanitic  resonance 
over  the  stomach  is  generally  high  in  pitch,  and 
frequently  has  a  ringing  or  metallic  intonation. 
The  gastric  tympanitic  resonance  recognized  by 
these  characters,  will  be  found  to  be  involved  fre- 
quently in  sounds  produced  by  percussing  over  the 
chest.  Gas  in  the  caecum  gives  a  still  higher  pitch 
of  resonance.  Over  the  colon  the  resonance  is  lower 
than  over  the  caecum  and  stomach,  and  it  is  still 
lower  over  the  small  intestines.  In  all  these  situa- 
tions, bringing  the  tympanitic  in  contrast  with  the 
normal  vesicular  resonance,  the  peculiar  quality  of 
the  latter  and  its  lowness  of  pitch  are  rendered  ap- 
parent. The  term  tympanitic  resonance  will  be 
found  to  enter  into  the  names  of  two  of  the  morbid 
signs  obtained  by  percussion. 

Having  studied  the  characters  of  the  normal 
vesicular  resonance,  and  become  practically  familiar 
with  them  by  percussing  different  healthy  persons, 
the  student  should  study  the  variations  which  this 
resonance  presents  in  the  different  regions  of  the 
chest.  In  doing  this  he  acquires  more  and  more 
tact  in  the  performance  of  percussion,  and  becomes 
more  and  more  familiar  with  the  characters  in 
general  of  the  normal  vesicular  resonance. 

Supra,  or  Post-clavicular  Region. — The  resonance 
here  varies  much  in  intensity  in  different  persons. 
The  vesicular  quality  is  most  marked  in  the  central 
portions.     Towards  the  sternal  extremity  the  reso- 


RESONANCE    IN    DIFFERENT    REGIONS         51 

nance  acquires  a  tympanitic  quality  from  the  prox- 
imity to  the  trachea ;  it  becomes  vesiculo-tympanitic,  • 
a  term  which  will  be  applied  to  one  of  the  morbid 
signs. 

Clavicular  Region. — Near  the  sternum  the  reso- 
nance is  somewhat  tympanitic  from  the  proximity 
to  the  trachea.  At  the  central  portion  the  vesicular 
quality  is  more  or  less  marked,  and  the  intensity  is 
diminished  at  the  acromial  extremity. 

Infra-clavicular  Region. — The  resonance  in  this  re- 
gion is  more  intense  than  elsewhere,  except  in  the 
axillary  and  the  infra-scapular  regions.  The  vesic- 
ular quality  is  combined  with  a  tympanitic  quality 
toward  the  sternum,  the  latter  being  derived  from 
the  primary  and  secondary  bronchi.  As  always 
when  the  vesicular  and  the  tympanitic  quality  are 
combined,  the  pitch  is  raised.  This  combination  in 
health  and  disease  is  recognized  by  the  intensity, 
pitch,  and  quality. 

Scapular  Region. — The  resonance  in  this  region  is 
notably  less  intense  than  in  the  infra-clavicular  re- 
gion, owing  to  the  presence  of  the  scapula  and  its 
muscles.  In  proportion  as  the  intensity  is  less,  the 
vesicular  quality  is  less  marked.  The  resonance  in 
health,  however,  is  quite  sufficient  for  morbid  Bigns 
to  be  available  in  this  situation. 

Interscapular  Region. — The  resonance  in  this  re- 
gion is  weak  in  comparison  with  other  regions,  ex- 

cept  the  scapular,  owing   to   the  muscles  which  here 

cover  the  chest  In  the  upper  part  o\'  the  region 
the  resonance  ie  Bomewhal  tympanitic  from  the  re- 
lation to  the  trachea  and  bronchi. 


52  PERCUSSION    IN    HEALTH 

Mammary  Region. — The  right  and  the  left  mam- 
mary region  are  to  be  studied  with  reference  to 
differences  relating  to  the  liver  and  the  heart.  On 
the  right  side,  from  the  fourth  rib  downward,  the 
resonance  is  diminished,  the  convex  extremity  of 
the  liver  extending  up  to  this  height.  At  or  a  little 
below  the  lower  border  of  this  region  on  the  mam- 
mary line,  that  is,  a  vertical  line  passing  through  the 
nipple,  resonance  ceases,  the  lower  lobe  of  the  right 
lung  not  extending  below  this  point.  Between  the 
third  and  fifth  ribs  on  this  side  near  the  sternum, 
the  resonance  is  diminished,  from  the  presence  of  a 
portion  of  the  right  auricle  and  ventricle.  On  the 
left  side  the  resonance  is  diminished,  within  the  pre- 
cordial space.  This  space  extends  vertically  from 
the  third  rib  to  the  fifth  intercostal  space,  and  hori- 
zontally from  the  sternum  to  a  point  at  or  a  little 
within  the  mammary  line.  The  resonance  is  con- 
siderably diminished  within  what  is  called  the 
superficial  cardiac  space.  This  space  may  be  rep- 
resented by  a  right-angled  triangle,  the  right  angle 
formed  by  a  vertical  line  drawn  from  a  point  on  the 
median  line  intersected  by  a  horizontal  line  connect- 
ing the  fourth  ribs,  and  a  horizontal  line  intersecting 
the  point  of  apex-beat  in  the  fifth  intercostal  space ; 
an  oblique  line  drawn  from  the  centre  of  the  sternum 
on  a  level  with  the  fourth  rib  and  the  point  of  apex- 
beat  forms  the  hypothenuse  of  the  right-angled 
triangle.  This  oblique  line  is,  in  fact,  a  curved, 
not  a  straight,  line  {vide  Fig.  1,  p.  36),  the  convexity 
looking  to  the  left  side.  Practically,  however,  it  is 
near  enough  to  accuracy  to  consider  it  the  hypothe- 
nuse of  a  right-angled  triangle.     Within  this  space 


RESONANCE    IN    DIFFERENT    REGIONS.      53 

the  heart  is  in  contact  with  the  thoracic  wall.  With- 
out this  space  and  within  the  pnecorclia  the  heart  is 
covered  with  lung,  and  the  resonance  on  percussion 
is  less  diminished.  It  is  a  useful  exercise  for  the 
student  to  observe  the  diminution  of  the  area  of  the 
superficial  cardiac  space  by  a  forced  inspiration,  as 
determined  by  percussion.  Aside  from  the  presence 
of  the  heart  and  the  convex  extremity  of  the  liver, 
the  resonance  over  the  mammary  is  less  than  in  the 
infra-clavicular  region,  being  diminished  by  the  pec- 
toral muscle,  which  varies  considerably  in  bulk  in 
different  persons,  and  in  women  by  the  mammary 
gland,  the  size  of  the  latter  varying  very  much  in 
different  women.  The  development  of  the  mammas, 
however,  is  never  so  great  as  to  preclude  the  useful 
employment  of  percussion  in  this  region. 

Infra-mammary  Region. — In  this  region,  as  in  the 
region  above  it,  the  two  sides  present  notable  differ- 
ences owing  to  the  situation  of  the  organs  below  the 
diaphragm.  (  m  the  right  side,  over  the  greater  part, 
and  sometimes  the  whole  of  this  region,  resonance 
is  wanting,  thai  IB,  percussion  gives  flatness.  It  is 
easy  to  delineate  the  boundary  between  the  lower 
border  of  the  right  lung  and  the  liver,  or,  as  it  is 
called,  this  line  of  hepatic  flatness.  It  is  also  easy  to 
distinguish  above  this  line  the  height  to  which  the 
upper  extremity  of  the  liver  extends,  or,  as  it  is 
called,  tfu  line  of  hepatic  dulness.  The  situation  of 
both  these  lines  varies  considerably  in  different 
healthy  persons.  The  distance  between  the  two 
lines  is  from  one  to  two  inches.  Both  lines  are 
affected  considerably  by  a  forced  inspiration  and  a 
forced  expiration.      A   forced  inspiration  deprec 


54  PERCUSSION    IN    HEALTH. 

the  line  of  flatness  about  one  and  a  half  inch.  A 
forced  expiration  causes  the  line  to  rise  from  two 
and  a  half  to  five  and  a  half  inches.  The  distance, 
therefore,  between  this  line  at  the  end  of  a  forced 
expiration,  and  at  the  end  of  a  forced  inspiration 
varies  from  four  to  seven  inches.  With  reference 
to  the  practice  of  percussion,  as  well  as  for  the  pur- 
pose of  verification,  these  points  should  be  studied. 
Not  infrequently  percussion  over  the  right  infra- 
mammary  region  yields  a  tympanitic  resonance  due 
to  the  distention  with  gas  of  the  transverse  colon. 

On  the  left  side,  the  resonance  in  this  region  varies 
in  different  persons,  in  the  same  persons  at  different 
times,  and  in  different  portions  of  the  region  at  the 
same  time,  the  variations  depending  on  the  organs 
below  the  diaphragm.  Flatness  is  caused  by  the 
extension  of  the  left  lobe  of  the  liver  into  this  re- 
gion about  three  inches  to  the  left  of  the  median 
line.  The  left  portion  of  the  region  is  in  relation  to 
the  spleen,  an  organ  which  varies  considerably  in 
size  in  health  as  well  as  disease,  its  average  dimen- 
sions being  about  four  inches  in  length  and  three 
inches  in  width.  Between  the  spleen  and  the  liver 
lies  the  stomach,  the  volume  of  which  is  constantly 
fluctuating,  owing  to  its  varying  solid,  liquid,  and 
gaseous  contents.  Distention  of  the  stomach  with 
gas  occasions  a  tympanitic  resonance  which  fre- 
quently is  transmitted  above  into  the  mammary  re- 
gion in  health  as  well  as  in  disease.  The  space 
corresponding  to  the  spleen  is  determined  by  the 
vesicular  resonance  above  and  the  tympanitic  reso- 
nance beloT.v,  the  latter  boundary,  however,  not 
being  very  reliable  on  account  of  the  ready  conduc- 


RESONANCE    IN    DIFFERENT    REGIONS.        55 

tion  of  tympanitic  resonance  for  a  certain  distance. 
The  distention  of  the  stomach  with  solid  or  liquid 
contents,  of  course,  occasions  flatness.  The  study 
of  the  infra-mammary  regions  with  reference  to  the 
variations  in  resonance  arising  from  the  relations  to 
the  organs  below  the  diaphragm,  is  of  much  utility 
from  the  practice,  as  well  as  the  knowledge,  which 
it  involves.  The  exercise,  of  endeavoring  to  define 
the  boundaries  of  these  different  organs  in  healthy 
persons,  will  be  of  great  service  to  the  student  in 
acquiring  tact  in  percussion,  and  in  discriminating 
differences  in  the  sounds  obtained  by  this  method. 

Sternal  Regions. — In  the  upper  sternal  region,  that 
is,  above  the  lower  margin  of  the  second  rib,  the 
resonance  is  non-vesicular,  being  derived  from  air 
in  the  trachea  above  the  point  of  bifurcation.  Being 
non-vesicular,  it  is,  of  course,  tympanitic,  inasmuch 
as  the  resonance  is  always  tympanitic  in  quality  if 
wholly  devoid  of  the  vesicular  quality.  Between 
the  second  and  third  ribs,  the  inner  borders  of  the 
two  lungs  approximating,  the  resonance  has  a  ves- 
icular quality  more  or  less  marked;  but  owing  to 
the  remnant  of  the  thymus  gland,  together  with 
adipose  substance,  and  the  presence  of  the  large 
the  resonance  is  nol  intense  in  this  situation. 
Below  the  third  rib  the  resonance  has  modifications 
due  to  the  combination  of  several  differenl  organs 
situated  beneath  the  lower  sternal  region.  <>n  the 
right  side  of  the    mesial    line   is   the  inner  border  of 

the  right  lung,  the  greater  part  of  the  right  and  a 
portion  of  the  left  ventricle  of  the  bearl  lying  be- 
neath ;  a  portion  of  the  liver  extends  into  the  lower 
part  of  this  region,  and  a  portion  of  the  stomach 


56  PERCUSSION    IN    HEALTH. 

when  distended.  The  resonance  thus  varies  in 
different  situations,  and  often  presents  a  mixed 
character.  It  is  a  useful  exercise  to  endeavor  to  de- 
fine by  percussion  the  boundaries  of  the  several 
organs  which  are  here  in  juxtaposition. 

Infra-scapular  Regions. — The  resonance  below  the 
scapula  is  intense  as  compared  with  that  over  the 
scapula,  and  the  vesicular  quality  is  marked.  The 
resonance  extends  to  the  eleventh  rib,  which  is  the 
lower  boundary  of  the  lung.  On  the  right  side,  at 
or  near  this  point,  is  the  line  of  hepatic  flatness, 
hepatic  dulness  extending  from  one  to  two  inches 
above  this  line.  The  line  of  hepatic  flatness  and  of 
hepatic  dulness  is  lowered  from  one  to  two  inches 
by  a  deep  inspiration,  and  raised  by  a  forced  expira- 
tion. On  the  left  side  the  resonance  may  receive  a 
tympanic  quality  from  the  presence  of  gas  in  the 
stomach. 

Lateral  Regions. — In  these  regions  the  resonance 
is  relatively  intense,  and  notably  vesicular.  On  the 
right  side  the  line  of  hepatic  flatness  is  at  the  eighth 
rib,  hepatic  dulness  extending  above  this  line  as  in 
front  and  behind.  On  the  left  side  the  resonance 
may  be  rendered  somewhat  dull  by  the  presence  of 
the  spleen,  but  it  often  has  a  tympanitic  quality  from 
the  presence  of  gas  in  the  stomach. 

As  has  been  stated,  the  normal  vesicular  resonance 
is  not  in  all  persons  identical  as  regards  intensity, 
pitch,  and  quality.  There  is,  therefore,  no  fixed 
standard  in  these  respects  by  which  we  can  deter- 
mine whether  the  resonance  be  normal  or  not.  The 
standard  proper  to  each  person  is  to  be  ascertained 
by  a  comparison  of  the  two  sides  of  the  chest ;  each 


RESONANCE    IN    DIFFERENT    REGIONS.       57 

person,  in  other  words,  furnishes  his  own  standard  of 
health.  But  it  is  to  be  observed  that  all  the  regions 
do  not  normally  correspond  in  respect  of  the  reso- 
nance on  the  two  sides.  In  the  following  regions  the 
resonance  is  notably  dissimilar  on  the  two  sides:  The 
mammary,  the  infra-mammary, the  infra-axillary, and 
the  infra-scapular.  There  is  less  disparity  in  the 
resonance  on  the  two  sides  in  the  following  regions  : 
The  supra-clavicular,  clavicular  and  infra-clavicular, 
the  scapular  and  inter-scapular,  and  the  axillary. 
In  some  of  these  regions,  however,  the  resonance 
differs,  and  it  is  of  practical  importance  to  note  the 
dissimilarity  which  thus  belongs  to  health.  This 
statement  applies  especially  to  the  infra-clavicular 
region,  a  region  which,  as  will  be  seen  hereafter,  is 
of  great  importance  with  reference  to  the  signs  of 
phthisis.  In  this  region  the  resonance  on  the  left 
side  is  somewhat  more  intense,  more  vesicular,  and 
lower  in  pitch  than  is  the  resonance  on  the  right 
Bide;  per  contra,  the  resonance  is  less  intense,  less 
vesicular,  and  higher  on  the  right  side.  This  ac- 
count of  these  points  of  disparity  between  the  two 
sides  is  based  on  an  analogy  of  recorded  observa- 
tions in  a  series  of  healthy  persons.1  The  student 
>lo >iib  1  become  practically  familiar  with  the  normal 
differences  between  the  two  sides,  and  iii  becoming 
lie  practical  experience  acquired  in  performing 
percussion   .vill  he  of  Q86. 

The  normal  resonance  is  affected  by  age.  In 
early  life,  when  the  costal  cartilages  are  flexible  and 
elastic,  the  resonance   18   more   intense  ami  lower  in 

1  Yhir  Physical  Exploration  of  the  Cheat  by  the  Author,  L£ 


58  PEKCDSSION    IN    HEALTH. 

pitch  than  in  old  age,  when  the  cartilages  are  rigid 
and  the  vesicular  structure  of  the  lung  more  or  less 
atrophied. 

The  resonance  varies  considerably  in  the  different 
regions  at  the  end  of  a  full  inspiration  and  at  the 
end  of  a  forced  expiration.  With  regard  to  this 
disparity,  the  following  is  an  extract  from  a  work 
on  physical  exploration,  published  by  the  author  in 
1856  : 

"  The  percussion-sound  may  also  be  found  to  vary 
at  different  periods  of  an  act  of  respiration  in  the 
same  individual.  The  quantity  of  air  contained 
within  the  air-cells,  and  consequently  the  relative 
proportion  of  air  and  solids,  are  by  no  means  equal 
after  a  full  inspiration  and  after  a  forced  expiration. 
The  difference  in  lung  expansion  may  occasion  an 
appreciable  disparity  in  resonance,  according  as  the 
percussion  is  made  at  the  conclusion  of  a  full  in- 
spiration, or  a  forced  expiration.  The  disparity  is 
not  appreciable  uniformly  in  different  persons.  This 
fact  I  have  ascertained  by  noting  the  results  of  ex- 
aminations made  with  reference  to  the  point.  When 
it  does  exist,  it  usually  consists,  contrary  to  what 
might  perhaps  have  been  anticipated,  and  the  re- 
verse of  what  is  usually  stated  in  works  on  physical 
exploration,  in  diminished  resonance  and  elevation 
of  pitch  at  the  conclusion  of  inspiration.  This  is 
probably  to  be  explained  by  the  greater  degree  of 
tension  of  the  lungs  and  thoracic  walls  produced  by 
inspiration  voluntarily  prolonged  and  maintained — 
a  condition  presenting  physical  obstacles  to  sonorous 
vibrations  more  than  sufficient  to  counterbalance  the 
increased  proportion  of  air  within  the  cells.     It  is  a 


RESONANCE    IN    DIFFERENT    REGIONS. 

curious  fact,  worthy  of  notice,  that  the  two  sides  of 
the  chest  are  not  always  found  to  be  affected  equally 
as  regards  the  percussion-sound,  at  the  conclusion 
of  a  full  inspiration,  contrasted  with  that  after  a 
forced  expiration.  I  have  observed  the  contrast  to 
be  more  striking  on  the  right  than  on  the  left  side; 
and  in  one  instance  on  the  left  side,  the  resonance 
was  less  intense  and  somewhat  tympanitic  after  a 
full  inspiration,  while  on  the  right  side  the  opposite 
effect  was  produced,  and  the  sound  became  quite 
dull  after  a  forced  expiration.  In  view  of  these 
variations  in  a  certain  proportion  of  instances  inci- 
dent to  different  periods  of  a  single  act  of  respira-' 
tion,  in  some  cases  of  disease  in  which  it  is  desirable 
to  observe  great  delicacy  in  the  correspondence  of 
the  two  sides,  pains  should  be  taken  to  percuss  cor- 
responding points  at  a  similar  stage  of  respiration, 
and  the  close  of  a  full  inspiration  is,  perhaps,  the 
period  to  be  preferred.  Ordinarily,  the  liability  to 
error  from  this  source  is  obviated,  either  by  repeat- 
ing a  series  of  strokes,  first  on  one  side  and  next 
on  the  other,  or  by  percussing  both  sides  repeatedly 
in  quick  succession,  in  order  mentally  to  obtain  the 
average  intensity  and  other  characters  of  the  sound 
dining  the  successive  stages  of  a  respiration.  The 
instances  of  disease,  however,  are  exceedingly  rare, 
in  which  such  nicety  of  discrimination  is  important." 
Prof.  Da  Costa  lias  recently  studied  more  fully  t  he 
variations  in  this  reaped  in  the  ditlerent  regions  in 
disease  as  well  as  in  health,  and  he  has  distinguished 

this  as  -i  respiratory  percussion."1 

1  Vide  work  on  l»i  »urth  edition,  1876. 


60  PERCUSSION    IN     HEALTH. 


Rules  in  the  Practice  of  Percussion. 

1.  Prior  to  a  comparison  of  the  two  sides  of  the 
chest,  as  regards  the  resonance  on  percussion,  either 
in  health  or  disease,  an  examination  by  inspection 
should  be  made,  in  order  to  determine  whether 
there  be  any  deviation  from  the  normal  conforma- 
tion. In  what  has  been  stated  concerning  percus- 
sion in  health,  it  is  assumed  that  the  chest  is 
symmetrical.  Want  of  symmetry  may  be  due  to 
congenital  deformities,  and  to  those  caused  by  ra- 

•chitis,  chronic  pleurisy,  curvature  of  the  spine,  and 
injuries.  An}7  deviation  from  the  normal  conforma- 
tion will  affect  more  or  less  the  resonance  in  corre- 
sponding regions  on  the  two  sides.  Due  allowance 
is  to  be  made  for  want  of  symmetry  in  determining 
morbid  signs,  and  often  the  existence  of  these  cannot 
be  determined  with  positiveness  when  there  is  con- 
siderable deformity.  The  signs  obtained  by  auscul- 
tation are  less  affected  by  want  of  symmetry  than 
those  obtained  by  percussion. 

2.  Attention  to  the  position  of  the  person  exam- 
ined is  important  with  reference  to  the  normal  sym- 
metry of  the  chest.  If  the  person  be  standing  or 
sitting,  the  position  should  be  upright  and  the 
shoulders  brought  to  a  level.  A  little  inclination 
of  the  body  to  one  side,  or  a  depression  of  one 
shoulder,  will  be  found  to  affect  perceptibly  the 
normal  resonance,  when  the  two  sides  are  com- 
pared. If  the  body  be  recumbent,  it  should  be  as 
nearly  as  possibly  on  a  level  plane.     These  condi- 


RULES    IN    PRACTICE    OF    PERCUSSION.       61 

tions  are  indispensable  for  a  nice  comparison  of  the 
two  sides  either  in  health  or  disease. 

3.  In  making  a  nice  comparison,  the  person  who 
percusses  should  be,  as  nearly  as  possible,  either  in 
front  or  behind  the  person  percussed.  Percussion 
made  by  one  standing  or  sitting  by  the  side  of  the 
person  percussed,  is  almost  certain  to  produce  dis- 
parity in  resonance. 

4.  Percussion  made  successively  on  one  side  and 
the  other  side,  must  be  in  all  respects  the  same  in 
regard  to  the  mode,  the  force  of  the  blow,  and  the 
situation.  A  light  percussion  on  one  side,  and  a 
strong  percussion  on  the  other  side,  will,  of  course, 
cause  a  disparity  in  the  intensity  of  resonance.  The 
percussion  must  be  made  in  succession  at  points  as 
nearly  as  possible  equidistant  from  the  median  line, 
and  from  the  summit  or  base  of  the  chest.  With 
reference  to  greal  nicety,  the  percussion,  if  made  on 
the  rib  or  intercostal  space  on  one  side,  must  be 
made  on  the  rib  or  intercostal  space  on  tin'  other 
side.  Great  nicety  of  comparison  also  requires  that 
if  the  percussion  be  made  on  one  side  during  the 
act  of  inspiration,  it  should  be  made  on  the  other 
side  during  this  act.  The  Bigns  of  disease,  however, 
are  generally  bo  well  marked,  that  very  close  atten- 
tion to  these  point-  is  not  necessary. 

.").  A  scries  of  blows  in  rapid  succession  (5  or  7)  is 
to  be  preferred  to  one  or  two,  in  practising  percus- 
sion, difference  in  intensity,  pitch,  and  quality  being 
thereby  better  appreciated. 

6 


62  PERCUSSION    IN    HEALTH. 

6.  Percussion  may  be  made  lightly  or  forcibly, 
the  former  being  called  superficial,  and  the  latter 
deep  percussion.  With  light  blows  the  resonance 
comes  from  the  superficies  of  the  lung  and  from 
within  a  limited  area.  With  forcible  blows  the 
resonance  is  from  a  greater  depth  and  a  wider 
space.  The  result  of  these  different  modes  of  prac- 
tising percussion  may  be  illustrated  within  the  prse- 
cordia  in  health.  Comparing  the  resonance  over 
the  superficial  cardiac  space  with  that  in  a  corre- 
sponding situation  on  the  right  side,  dulness  is  more 
marked  with  light  than  with  forcible  blows,  the 
resonance  from  the  latter  coming  from  a  wider  area. 
On  the  other  hand,  comparing  the  resonance  over 
the  deep  cardiac  space,  dulness  is  more  marked  with 
forcible  than  with  light  blows,  owing  to  the  presence 
of  lung  between  the  heart  and  the  walls  of  the  chest. 
This  rule  is  of  importance  in  its  application  to  per- 
cussion in  disease. 

7.  Percussion  over  the  anterior  portion  of  the 
chest,  the  person  percussed  leaning  against  a  door, 
a  board  partition,  or  a  lathed  wall,  gives  an  increased 
intensity  of  resonance.  It  is  often  useful  to  resort 
to  this  procedure  in  the  practice  of  percussion. 


CHAPTER  TIT. 

PERCUSSION  IX  DISEASE. 

Enumeration  of  the  signs  of  disease  furnished  by  percussion — Require- 
ments for  a  practical  knowledge  of  these  signs — The  distinctive 
characters  of  the  morbid  physical  conditions  represented  by,  and  the 
different  diseases  into  the  diagnosis  of  which  enter,  the  signs,  sever- 
ally, to  wit,  1.  Absence  of  resonance  or  flatness;  2.  Diminished  reso- 
nance; .°).  Tympanitic  resonance;  i.  Vesiculotympanitic  resonance; 
5.  Amphoric  resonance;  6.  Cracked-metal  resonance — Sense  of  resist- 
ance felt  in  the  practice  of  percussion,  as  a  morbid  sign. 

Percussion  in  cases  of  disease  furnishes  signs 
which  represent  morbid  physical  conditions  incident 
to  the  different  pulmonary  affections;  with  these 
physical  conditions  and  their  relations  to  pulmonary 
affections  the  student  is  supposed  to  be  familiar  (vide 
page  20  et  seq.). 

The  signs  of  disease  furnished  by  percussion  arc 
resolvable  into  six,  namely:  1.  Absence  of  reso- 
nance or  flatness;  2.  Diminished  resonance  or  dul- 
aess;  3.  Tympanitic  resonance;  4.  Vesiculotym- 
panitic resonance;  5.  Amphoric  resonance,  and  6. 
Cracked-metal  resonance.  The  two  last  named 
signs  an-  properly  varieties  of  tympanitic  resonance, 
but  it  is  most  convenient  to  consider  them  as  dis- 
tinct signs. 

Knowledge  of  these  six  signs  sufficient  for  their 
availability  in  physical  diagnosis  requires,  jhsf,  a 
practical  acquaintance  with  the  characters  which 
distinguish  each  from  the  others,  as  well  as  from 


64  PERCUSSION    IN    DISEASE. 

the  normal  resonance  :  and  second,  a  clear  apprehen- 
sion of  the  significance  of  each,  that  is,  the  morbid 
physical  conditions  which  they  severally  represent. 
Under  these  two  aspects  the  signs  will  now  be  con- 
sidered. 

1.  Absence  of  Resonance  or  Flatness. 

This  sign  is  sufficiently  defined  by  its  name.  It 
is  absence  of  resonance  or  sound.  Nothing  is  heard 
but  a  noise  such  as  may  be  produced  by  percussing 
over  a  solid  mass,  for  example,  a  limb  composed  of 
muscle  and  bone,  or  over  a  collection  of  liquid,  for 
example,  the  abdomen  in  hydro-peritoneum  or 
ascites.  There  being  no  resonance  or  sound,  the 
sign  has  no  characters  pertaining  to  pitch  or  quality. 
It  may  be  illustrated  on  the  healthy  chest  by  percuss- 
ing in  the  right  infra-mammary  region  below  the 
line  of  hepatic  flatness. 

There  are  four  classes  of  morbid  physical  condi- 
tions giving  rise  to  flatness  on  percussion,  namely, 
1st,  the  presence  of  liquid  either  in  the  pleural  sac 
or  in  pulmonary  cavities;  2d,  liquid  filling  the  air- 
vesicles;  3d,  complete  solidification  of  lung;  and, 
4th,  a  tumor  within  the  chest.  Flatness  on  percus- 
sion always  represents  one  of  these  morbid  physical 
conditions. 

These  conditions  are  incidents  to  different  dis- 
eases, as  follows : 

1st.  Liquid  in  the  pleural  cavity  is  incident  to 
pleurisy  with  effusion,  empyema,  and  hydrothorax. 
A  collection  of  pus  constitutes  pulmonary  abscess, 
and  phthisical  cavities,  or  those  caused  by  circum- 


ABSENCE    OF    RESONANCE    OR    FLATNESS.      65 

scribed  gangrene,  may  become  filled  with  morbid 
liquid  products. 

2d.  Serous  effusion  into  the  air-vesicles  consti- 
tutes pulmonary  oedema.  Liquid  blood  extravasated 
characterizes  hemorrhagic  infarctus,  pneumorrhagia 
or  pulmonary  apoplexy.  Pus  infiltrating  more  or 
less  of  the  parenchyma  may  be  derived  from  an  ab- 
scess either  within  the  lung,  or  elsewhere,  for  ex- 
ample, the  liver,  and  from  the  pleural  cavity  in 
empyema  when  perforation  of  lung  takes  place. 

3d.  Solidification  of  lung  occurs  in  pneumonia 
from  an  exudation  within  the  air-cells;  it  is  pro- 
duced by  condensation  from  compression  by  liquid 
or  air  in  the  pleural  sac,  the  pressure  of  a  tumor, 
and  by  collaDse;  it  exists  in  cases  of  phthisis,  in  in- 
terstitial pneumonia,  and  in  carcinomatous  infiltra- 
tion of  lung. 

4th.  Tumors  within  the  chest  are  of  different 
kinds,  for  examples,  aneurisms  and  cancerous 
growths.  In  proportion  to  their  size  they  occupy 
space  belonging  to  the  lung,  as  well  as  condensing 
the  latter  by  pressure.  Flatness  may  also  be  caused 
by  the  encroachment  of  organs  situated  below  the 
diaphragm  upon  the  thoracic  space,  as  in  cases  of 
enlargement  of  the  liver  and  spleen. 

Flatness  on  percussion  in  all  these  conditions  is 
the  .-ainc.  The  Bign  alone  does  not  enable  as  to 
discriminate  the  conditions  from  each  other,  nor  to 
determine  the  existing  disease. 

Finding  this  sign  present,  the  particular  condition 
ami  the  disease  in  each  case  are  to  be  determined  by 
the  situation  of  the  flat n ess,  its  extent,  the  associated 
physical  Bigns  furnished   by  auscultation,  together 


6Q  PERCUSSION    IN    DISEASE. 

with  the  other  methods  of  exploration,  and  by  the 
symptomatic  phenomena. 

2.  Diminished  Resonance  or  Dulness. 

The  resonance  on  percussion  is  diminished.?  or 
there  is  dulness,  when  the  solids  or  liquids  within 
the  chest  are  morbidly  increased  without  increase 
in  the  quantity  of  air,  the  increased  amount  of  solids 
or  liquids  not  being  sufficient  to  cause  flatness. 
Diminution  of  air  without  increase  of  either  solids 
or  liquids,  as  in  collapse  of' pulmonary  lobules,  also 
gives  rise  to  dulness.  We  may  formularize  the 
physical  conditions  by  saying  that  they  consist  in 
an  abnormal  proportion  of  solids  or  liquids  over  the 
air  in  the  pulmonary  vesicles. 

Dulness  varies  in  degree.  It  may  be  slight, 
moderate,  considerable,  or  great.  These  adjectives 
of  quantity  express  sufficiently  the  variations  in  this 
regard.  The  degree  of  dulness  corresponds  to  the 
amount  of  the  relative  disproportion  of  solids  or 
liquids  over  the  air  within  the  chest. 

The  pitch  of  sound  is  higher  than  that  of  the 
normal  resonance  of  the  persons  percussed.  This 
is  invariable;  with  dulness  there  is  always  more  or 
less  elevation  of  pitch.  The  quality  is  altered  only 
in  amount;  there  is,  of  course,  less  vesicular  quality 
in  proportion  as  the  intensity  of  the  resonance  is 
diminished. 

The  characters  which  distinguish  this  sign,  thus, 
are,  lessened  intensity  of  resonance,  elevation  of 
pitch,  and  weakened  vesicular  quality. 

The  morbid  conditions  giving  rise  to  this  sign  are 


DIMINISHED    RESONANCE    OR    DULNESS.      G7 

those  which,  existing  in  a  greater  degree,  give  rise 
to  flatness.  Morbid  products  within  the  pleural  sac, 
serum,  pus,  lymph,  if*  not  sufficient  to  cause  flatness, 
give  rise  to  dulness.  The  sign,  therefore,  occurs  in 
pleurisy,  empyema,  and  hydrothorax.  The  same  is 
true  of  pulmonary  cedema,  hemorrhagic  infarctus, 
pneumorrhagia,  and  purulent  infiltration  of  lung. 
Solidification  of  lung,  when  not  complete,  occasions 
dulness;  hence  it  is  a  sign  in  pneumonia,  vesicular 
and  interstitial,  in  phthisis,  in  condensation  of  lung 
from  compression,  in  collapse  of  pulmonary  lohules, 
and  in  carcinomatous  infiltration.  A  tumor  within 
the  chest,  not  sufficiently  large  to  cause  flatness, 
gives  rise  to  dulness. 

There  are,  however,  some  conditions  giving  rise 
to  dulness,  which  are  never  sufficient  to  cause  flat- 
ness. Pulmonary  congestion  limited  to  a  lobe  may 
diminish  the  resonance  appreciably.  The  dulness 
may  exist  in  the  first  stage  of  pneumonia,  before 
solidification  from  pneumonic  exudation  lias  taken 
place.  A  layer  of  lymph  upon  the  pleural  surfaces 
causes  dulness  after  the  liquid  effusion  in  pleurisy 
baa  been  removed,  and  after  the  vesicular  exudation 
in  pneumonia  is  absorbed.  Dulness  may  also  be 
caused  by  a  considerable  accumulation  of  mucus  or 
Emulated  blood  within  the  infra-pulmonary  bron- 
chial lu!' 

The  particular  morbid  condition  which  gives  rise 
to  dulness  cannot  be  inferred  from  the  characters  of 
the  sign  :  the  sign  only  denotes  thai  aome  one  of  the 
different  morbid  conditions  exists.  The  condition 
which  exists  in  each  caBO,  ;md    the  disease,  are  to  be 

determined  by  the  situation,  extent,  and  degree  of 


68  PERCUSSION    IN    DISEASE. 

dulness,  taken  in  connection  with  the  information 
derived  from  other  methods  of  exploration  than  per- 
cussion, together  with  the  history  and  symptoms. 

3.  Tympanitic  Resonance. 

Resonance  is  tympanitic  whenever  it  is  entirely 
devoid  of  the  vesicular  quality ;  in  other  words,  any 
resonance  which  is  non-vesicular  is  tympanitic.  The 
leading  distinctive  character  of  the  preceding  sign 
(dulness)  relates  to  intensity,  whereas,  the  leading 
distinctive  character  of  this  sign  relates  to  quality. 
Tympanitic  resonance  derives  no  distinctive  char- 
acter from  intensity ;  it  may  be  either  more  or  less 
intense  than  the  resonance  of  health  in  the  person 
percussed.  This  point  is  to  be  emphasized,  inas- 
much as  with  many  the  idea  of  tympanitic  resonance 
involves  increased  intensity  of  sound;  a  resonance, 
be  it  never  so  feeble,  if  it  be  non-vesicular,  is  tym- 
panitic. If,  however,  the  resonance  be  quite  feeble, 
it  is  not  always  easy  to  determine  whether  there  be, 
or  be  not,  any  appreciable  vesicular  quality.  The 
term  used  by  Stokes,  namely,  "  tympanitic  dulness," 
is  properly  enough  applied  to  a  resonance  with  di- 
minished intensity,  in  which  a  vesicular  quality 
cannot  be  appreciated.  As  regards  pitch,  a  tym- 
panitic resonance  is  higher  than  the  normal  vesic- 
ular resonance.  If  there  be  any  exceptions  to  this 
rule,  they  are  extremely  infrequent.  The  tympanitic 
resonance  over  different  parts  of  the  abdomen  is 
always  higher  in  pitch  than  the  resonance  over 
healthy  lung. 

The  following  are  the  morbid  physical  conditions 
which  give  rise  to  tympanitic  resonance : 


TYMPANITIC    RESONANCE.  69 

1st.  Air  ill  the  pleural  cavity.  It  is,  therefore,  a 
sign  of  pneumothorax.  Frequently  in  this  affec- 
tion the  tympanitic  resonance  is  more  intense  than 
the  resonance  of  health,  the  pitch  being  always  more 
or  less  raised. 

2d.  Pulmonary  cavities  containing  air.  It  occurs, 
therefore,  in  cases  of  phthisis.  In  this  disease  the 
tympanitic  resonance  is  limited  to  a  circumscribed 
space  corresponding  to  the  site  and  size  of  the  cavity, 
whereas,  in  pneumothorax,  it  frequently  exists  over 
a  considerable  part  or  the  whole  of  the  affected  side 
of  the  chest. 

3d.  Complete  solidification  of  the  whole  or  a  part 
of  the  upper  lobe  of  lung.  The  tympanitic  reso- 
nance under  these  circumstances  must  be  derived 
from  the  air  in  the  lower  part  of  the  trachea  and  the 
bronchial  tubes  exterior  to  the  lungs.  This  is  the 
explanation  of  the  sign  in  the  second  stage  of  pneu- 
monia affecting  an  upper  lobe,  and  in  certain  cases 
of  phthisis  prior  to  the  stage  of  excavation.  Dilata- 
tion of  the  intra-pulmonary  bronchial  tubes,  with 
solidification  surrounding  them,  as  in  some  cases  of 
interstitial  pneumonia  or  cirrhosis  of  lung,  may  give 
rise  to  tympanitic  resonance. 

4th.  ( londuction  of  resonance  from  the  stomach  or 
colon  containing  air  or  gas.  A  gastric  tympanitic 
resonance  is  frequently  conducted  over  a  part,  and 
Bometimes  over  the  whole,  "I"  the  left  side  of  the 
chest.  This  is  more  Likely  to  occur  when  the  left 
lung  is  solidified.  On  the  right  side  Less  frequently 
a  tympanitic  resonance  may  be  conducted  upward 
from  the  colon  to  a  greater  or  Less  extent 

Tympanitic  resonance  may  be  Illustrated  by  per- 


70  PERCUSSION    IN    DISEASE. 

cussion  over  the  hollow  abdominal  viscera  of  the 
abdomen,  provided  they  contain  air  or  gas.  The 
sign  may  be  imitated  by  percussing  an  inflated 
bladder  or  India-rubber  balls.  The  pitch  will  be 
found  to  vary  according  to  the  size  and  the 
degree  of  inflation  of  the  bladder  or  balls.  To 
illustrate  this  resonance  in  proximity  to  a  vesicular 
resonance  produced  artificially,  one-half  of  the  soft 
portion  of  an  oblong  loaf  of  bread  may  be  removed, 
leaving  intact  the  upper  crust.  Percussion  over  this 
half  of  the  loaf  illustrates  the  tympanitic,  and  over 
the  other  half  the  vesicular,  resonance. 

4.  Vesiculo-tympanitic  Resonance. 

This  name  was  proposed  by  the  author  many 
years  ago  to  denote  a  sign  with  the  following  dis- 
tinctive characters :  The  resonance  increased  in  in- 
tensity ;  the  quality  a  combination  of  the  vesicular 
with  a  tympanitic,  and  the  pitch  high  in  proportion 
as  the  tympanitic  quality  predominates  over  the 
vesicular. 

The  sign  represents  especially  one  morbid  phy- 
sical condition,  namely,  an  abnormal  accumulation 
of  air  in  consequence  of  dilatation  of  the  air- vesicles, 
that  is,  pulmonary  or  vesicular  emphysema.  The 
sign  also  is  present  in  interstitial  or  interlobular  em- 
physema. The  relation  of  the  sign  to  these  affec- 
tions renders  it  of  great  value  in  physical  diagnosis. 

A  vesiculo-tympanitic  resonance  is  obtained  when 
the  pleural  sac  is  partially  filled  with  liquid,  by  per- 
cussing over  the  lung  on  the  affected  side.  Although 
the  pressure  of  the  liquid  diminishes  the  volume  of 
the  lung,  as  a  rule  it  yields  this  sign.     The  reso- 


AMPHORIC    RESONANCE.  71 

nance  is  vesiculotympanitic  above  the  liquid  wheu 
the  latter  is  sufficient  to  till  a  third,  a  half,  or  even 
two-thirds  of  the  intra-thoracic  space.  The  sign  is 
also  obtained  over  the  upper  lobe  when  the  lower 
lobe  is  solidified  in  the  second  stage  of  pneumonia, 
and  over  the  lower  lobe  when  the  upper  lobe  ie 
solidified. 

A  loaf  of  bread  may  be  used  to  illustrate  a  vesic- 
ulotympanitic resonance,  as  follows  :  By  means  of 
a  hollow  cylinder  remove  longitudinal  sections  in 
one-half  of  the  loaf,  leaving  the  crust  intact.  The 
spaces  thus  produced  yield  a  tympanitic  resonance, 
and  the  portions  which  surround  these  spaces  give 
the  vesicular  resonance.  The  vesicular  and  the 
tympanitic  quality  are  thus  combined,  with  eleva- 
tion of  pitch  and  increased  intensity ;  over  the  other 
half  of  the  loaf  the  resonance  is  purely  vesicular. 
Another  method  of  illustrating  this  sign  out  of  the 
body  is  to  inflate  the  human  lungs,  or  the  lungs  of 
the  sheep  or  calf,  considerably  beyond  the  limit  of 
a  normal  inspiration.  Inflated  beyond  that  limit  the 
emphysematous  condition  is  produced, and  the  reso- 
nanee  represents  that  condition. 

5.  Amphoric  Resonance. 

Resonance  is  said  to  We  amphoric  when  it  has  a 
musical  Lntonatioo  analogous  to  that  produced  by 
blowing  over  the  mouth  of  an  empty  bottle.  An 
amphoric  sound  ie  easily  illustrated  by  filliping  the 
ehe<  k  made  tense,  the  mouth  not  completely  closed, 
and  the  jaw-  separated,  as  is  done  when  the  sound 
of  a  liquid  flowing  from  a  bottle  is  imitated.  \>\ 
varying  the  size  ol  the  cavity  of  the  mouth,  the  am- 


72  PERCUSSION    IN    DISEASE. 

phoric  sound  thus  produced  may  be  made  to  vary 
much  in  pitch.  This  illustration  exemplifies  the 
mechanism  of  the  sign  in  disease. 

The  sign  represents  a  pulmonary  cavity  which  is 
generally  phthisical.  The  conditions,  aside  from 
the  existence  of  the  cavity,  are,  rigidity  of  its  walls, 
so  that  they  do  not  collapse,  the  presence,  of  course, 
of  air  within  the  cavity,  and  free  communications 
with  the  bronchial  tubes.  These  accessory  condi- 
tions are  not  constant,  so  that  an  amphoric  resonance 
over  a  cavity  is  sometimes  found,  and  other  times 
wanting.  Directly  after  having  been  wanting,  it 
may  be  reproduced  if  the  patient  expectorate  freely. 

When  percussion  is  made  with  reference  to  this 
sign,  the  mouth  of  the  patient  should  be  open,  and 
one  or  two  rather  forcible  blows  are  better  than  a 
series  of  four  or  six.  The  amphoric  sound  may  be 
often  distinctly  perceived  if  the  ear  be  brought  into 
close  proximity  to  the  patient's  open  mouth,  when 
the  sign  is  not  appreciable  otherwise.  It  may  be 
rendered  still  more  distinct  by  means  of  the  binaural 
stethoscope,  the  pectoral  extremity  being  close  to 
the  mouth  of  the  patient. 

As  a  cavernous  sign  the  amphoric  resonance  is 
very  reliable ;  but  it  does  not  invariably  denote  a 
pulmonary  cavity.  It  is  obtained  in  some  cases  of 
pneumothorax,  the  pleural  space  tilled  with  air  form- 
ing a  cavity  which  communicates  with  the  bronchial 
tubes  through  a  perforation  of  the  lung  situated  above 
the  level  of  the  liquid.  It  is  sometimes  obtained  over 
a  solidified  portion  of  lung  situated  in  close  proximity 
to  a  primary  bronchus,  the  resonance  being  derived 
from  the   air  within   the  latter.     It  is   occasionally 


CRACKED-METAL    RESONANCE.  73 

produced  by  percussing  over  the  site  of  the  primary 
bronchus  in  the  second  stage  of  pneumonia  affecting 
an  upper  lobe.  In  children,  owing  to  the  yielding 
of  the  costal  cartilages,  it  may  even  be  produced  in 
health  over  a  primary  bronchus.  In  all  these  excep- 
tional instances  the  associated  signs  and  symptoms 
will  prevent  the  error  of  attributing  the  sign  to  a 
pulmonary  cavity. 

This  sign  is  properly  a  variety  of  tympanitic  reso- 
nance. 

6.  Cracked-metal  Resonance. 

The  name  of  this  sign,  expressing  an  analogy  to 
the  sound  produced  by  striking  a  cracked  metallic 
vessel,  denotes  its  peculiar  character.  It  may  be 
imitated  by  folding  the  hands  so  as  to  form  a  cavity 
and  Btriking  them  upon  the  knee,  in  the  familiar 
trick  of  producing  in  this  way  a  sound  as  if  metal 
coins  were  between  the  palms.  This  illustration, 
also,  exemplifies  the  mechanism  of  the  Bign.  Like 
1 1 1 •  -  Bign  last  described,  it  is  a  variety  of  tympanitic 
resonance. 

The  cracked-metal,  like  the  amphoric,  resonance 
represents  generally  a  phthisical  cavity.  Percussion 
i-  to  be  made  in  the  same  way  as  for  the  production 
of  the  amphoric  resonance,  and,  like  the  latter,  the 
cracked-metal  character  is  often  perceived  if  the  ear 

be  brought  close  to  the  patient's  mouth  when  other- 

u ise  it  is  not  appreciable. 

The  cracked-metal  ami  the  amphoric  resonance 
are  often  associated :  and  the  statements  made  with 
respect  to  the  exceptional    instances  in  which  the 


74  PERCUSSION    IN    DISEASE. 

latter  is  produced,  without  the  existence  of  a  pul- 
monary cavity,  will  apply  equally  to  the  former. 

In  addition  to  the  acoustic  phenomena  produced 
by  percussion  with  the  fingers  applied  to  the  chest 
instead  of  a  pleximeter,  an  abnormal  sense  of  resist- 
ance is  felt  in  certain  conditions  of  disease.  In 
health,  with  a  somewhat  forcible  percussion,  the 
walls  of  the  chest  are  felt  to  yield  in  proportion  as 
the  costal  cartilages  are  flexible.  This  yielding  is 
diminished  or  ceases  when  a  collection  of  liquid  in 
the  pleural  cavity,  or  liquid  in  the  air-vesicles,  and 
solidification  of  lung,  offer  a  mechanical  obstacle 
thereto.  An  abnormal  sense  of  resistance  on  per- 
cussion, thus  determinable  by  comparison  of  the 
two  sides  of  the  chest,  is  a  sign  representing  some 
one  of  the  morbid  physical  conditions  just  named. 
This  properly  belongs  among  the  signs  obtained  by 
palpation.  The  sign  is  to  be  taken  in  connection 
with  other  signs  in  determining  the  condition  which 
exists  in  particular  cases. 


CHAPTER  IV. 

AUSCULTATION  IN  HEALTH. 

Importance  of  the  study  of  the  auscultatory  sounds  in  health — Immediate 
and  mediate  auscultation — Advantages  of  the  binaural  stethoscope — 
Rules  to  be  observed  in  auscultation — Divisions  of  the  study  of  auscul- 
tation in  health — The  normal  laryngeal  and  tracheal  respiration — The 
normal  vesicular  murmur;  its  distinctive  characters,  and  the  variations 
in  the  different  regions  on  the  same  side,  and  in  corresponding  regions 
"ii  the  two  sides  of  the  chest — The  normal  vocal  resonance — The 
laryngeal  and  tracheal  voice  and  whisper — The  normal  thoracic  rooal 
resonance  and  fremitus;  the  distinctive  characters  of  each:  the  varia- 
tions in  different  regions  on  the  same  side,  and  in  corresponding  regions 
on  the  two  sides  of  the  chest — The  normal  bronchial  whisper,  with  its 
variations  in  different  regions  on  the  same  side,  and  in  corresponding 
regions  on  the  two  sides  of  the  chest. 

'I'm;  term  auscultation ,  limited  in  its  application 
to  the  respiratory  system,  denotes  the  act  of  listen- 
ing to  the  normal  and  abnormal  sounds  produced 
l'V  respiration,  voice,  and  cough.  In  this  and  the 
next  chapter,  the  method  of  exploration  thus  named 
will  be  considered  in  its  application  to  the  respira- 
tory system;  it  will  he  considered  subsequently  as 

applied  to  sounds  relating  to  the  circulatory  system. 

The  study  of  auscultatory  sounds  in  health  is 
ntial  as  preparatory  for  the  study  of  auscultation 
in  disease.  The  student  must  be  familiar  with  the 
normal  sounds  before  undertaking  to  become  ac- 
quainted with  those  which  repp-mi  morbid  condi- 
tions. Ample  time  and  attention  should  be  given 
to  the  study  of  auscultation  in  health.     The  omis- 


76  AUSCULTATION    IN    HEALTH. 

sion  to  do  this  is  a  frequent  cause  of  difficulty  and 
want  of  success  in  attaining  to  a  satisfactory  profi- 
ciency in  physical  diagnosis.  The  practical  skill  re- 
quired in  diagnosis  may  be  obtained  in  advance  by 
devoting  sufficient  study  to  the  healthy  chest  before 
entering  on  the  study  of  the  auscultatory  signs  of 
disease.  Moreover,  as  will  be  seen,  some  of  the 
most  important  of  the  morbid  signs  have  their 
analogues  in  certain  normal  sounds  pertaining  to  the 
respiratory  system. 

Auscultation  is  either  immediate  or  mediate.  It 
is  immediate  when  the  ear  is  applied  directly  to  the 
chest,  which  maybe  either  denuded  or  covered  with 
a  cloth  or  more  or  less  of  the  clothing.  It  is  mediate 
when  the  sounds  are  conducted  to  the  ear  by  means 
of  an  instrument  called  a  stethoscope.  The  student 
should  practise  both  immediate  and  mediate  auscul- 
tation. The  direct  application  of  the  ear  to  the 
chest  suffices  for  diagnosis  in  many  cases  of  disease; 
but  there  are  sometimes  objections  to  this  by  the 
patient  on  the  score  of  delicacy,  and  by  the  auscul- 
tator  on  the  score  of  the  uncleanliness  of  the  person 
examined.  There  are  certain  parts  of  the  chest  which 
can  only  be  explored  by  the  stethoscope,  and  this 
instrument  has  the  advantage  of  circumscribing  the 
space  whence  the  auscultatory  sounds  are  derived. 
Moreover,  by  means  of  the  stethoscope  which  is  to 
be  preferred  over  the  great  variety  of  instruments 
heretofore  in  use,  the  sounds  are  heard  much  better 
than  by  immediate  auscultation. 

The  stethoscope  which  is  to  be  preferred  conducts 
the  sounds  into  both  ears,  that  is,  it  it  binaural.  In 
this  consists  its  great  superiority.     At  the  present 


AUSCULTATION    IN    HEALTH. 


I  ( 


time  what  is  known  as  Cammann's  stethoscope1 
seems  to  combine  more  recommendations  than  any 
other  form  of  a  binaural  instrument.  (Fig.  8.)  The 
conduction  into  both  ears  renders  the  sounds  much 
louder  and  more  distinct  than  when  they  are  heard 
with  one  ear  in  either  mediate  or  immediate  auscul- 
tation. Another  advantage  is,  the  mind  is  not  dis- 
tracted by  sounds  entering  the  ear  not  employed  in 
auscultation.  The  advantages,  however,  of  Cam- 
mann's stethoscope  are  not  appreciated  until  after 

Fig.  8. 


i  femmann'a  Stethoscope. 


Borne  practice.  At  first,  a  humming  sound  is  heard 
which  divides  the  attention  and  thus  obscures  the 
intra-thoracic  sounds.  After  a  little  practice  this 
humming  sound  is  not  heeded,  and  it  erases  to  be 
any  obstacle.  Many  who  use  the  inst runient  Only 
;i  few  times  are  dissatisfied  with  it  and  discontinue 
it<  use,  when,  if  they  had  used  it  longer,they  would 
not  have  been  willing  to  dispense  with  it.  The 
author's  experience  with  a  large  number  of  classes 
in  private  instruction  has  been  this:  at  first,  mosl 
members  ofa  class  prefer  the  ear  applied  directly  to 

1  Invented  bj  the  late  Dr.  Cammann,  of  New  fork. 


78 


AUSCULTATION    IN    HEALTH 


the  chest ;  but,  before  the  course  of  instruction  is 
ended,  the  binaural  stethoscope  is  so  much  preferred 
that  it  is  difficult  to  enforce  a  fair  proportion  of  prac- 
tice in  immediate  auscultation. 

Another  reason  for  the  fact  that  this  stethoscope 
is  not  sufficiently  appreciated  in  this  country  is  that 
many  of  the  instruments  sold  are  defectively  made. 
Unless  proper  attention  has  been  paid  to  all  the  nice 
points  of  the  stethoscope  as  devised  by  Cammann, 
an  instrument  is  worthless.  An  instrument  must 
be  very  good,  or  it  is  without  value.      The  knobs 


Fiu.  9. 


Allison's  differential  stethoscope 


which  are  to  enter  the  ears  must  be  of  the  right 
size ;  if  they  enter  too  far  they  occasion  pain.  The 
curves  at  the  aural  extremity  must  be  such  that  the 
aperture  is  in  the  direction  of  the  meatus  of  the 
ear.  The  flexible  tubes  must  not  be  stiff,  and  their 
movements  must  be  noiseless.  All  the  tubes  must 
be  unobstructed,  for  it  is  the  air  within  the  tubes 
which  chiefly  conducts  the  sounds.  In  the  use  of 
the  instrument  it  should  be  applied  to  the  chest 
without  any  intervening  clothing.1 

1  The  stethoscopes  made  by  Tiemann  &  Co.  and  Ford  &  Co.  are 
reliable. 


AUSCULTATION    IN    HEALTH.  79 

The  stethoscope  known  as  Allison's  differential 
stethoscope  (videTPig.  9),  is  binaural  with  two  pectoral 
extremities.  With  this  instrument  intra-thoracic 
sounds  are  received  simultaneously  from  different 
situations.  This  stethoscope  is  only  useful  for  the 
comparison  of  sounds  as  regards  the  relative  time  of 
their  occurrence.  The  advantage  of  the  better  con- 
duction of  sounds  when  they  are  received  into  both 
ears  is,  of  course,  lost.  In  other  respects  than  the 
comparison  as  to  the  occurrence  of  sounds  synchro- 
nously, or  otherwise,  the  differential  stethoscope  has 
no  advantage.  A  little  reflection  and  practice  will 
suffice  to  show  that  to  compare  different  sounds  in 
respect  of  pitch  and  quality,  it  is  better  to  listen  to 
them  successively  than  simultaneously. 

The  rules  to  be  observed  in  the  practice  of  auscul- 
tation, in  health  and  disease,  may  be  here  introduced. 

In  auscultation,  as  in  percussion,  corresponding 
situations  on  the  two  sides  of  the  chest  are  to  be 
explored  successively,  and  compared.  When  the 
stethoscope  is  used,  the  pectoral  extremity  must 
be  applied  on  each  side  with  the  same  degree  of 
pressure;  this  is  especially  essential  in  the  com- 
parison of  vocal  sounds.  In  immediate  ausculta- 
tion, the  ear  is  t<>  be  applied  with  a  certain  degree 
of  force,  and  a  thin  layer  of  clothing  does  not  inter- 
fere materially  with  the  perception  of  auscultatory 
sounds.  The  ear  nol  applied  to  the  chesl  may  or 
may  not  be  closed  by  the  finger  in  Listening  to  the 
respiratory  sounds;  it  should  be  dosed  in  listening 
to  the  vocal  sounds,  in  order  to  prevent  confusion 
from  attention  to  the  voice  from  the  patient'-  month. 

In  immediate  auscultation,  whenever  practised,  the 


80  AUSCULTATION    IN    HEALTH. 

auscultator  should  take  a  position  which  will  not  in- 
terfere with  the  sense  of  hearing,  and  not  occasion  a 
feeling  of  discomfort.  These  difficulties  are  in  the 
way  of  auscultating  with  the  body  bent  forward; 
the  sense  of  hearing  is  dulled  by  the  detention  of 
blood  in  the  head,  and  the  position  cannot  be  main- 
tained without  discomfort.  The  person  examined, 
if  practicable,  should  be  sitting,  and  the  position  for 
the  auscultator  is  that  of  kneeling  on  one  knee,  and 
lowering,  if  necessary,  the  body,  so  that  the  head 
may  be  kept  upright.  These  points  are  less  im- 
portant if  the  binaural  stethoscope  be  used. 

When  listening  to  respiratory  sounds,  it  is  gener- 
ally desirable  that  the  person  examined  should 
breathe  with  somewhat  greater  force  than  in  ordi- 
nary breathing;  but  it  is  important  that  the  normal 
rhythm  of  respiration  should  be  unchanged.  Per- 
sons when  requested  to  breathe  with  increased  force 
are  apt  to  err  in  breathing  violently,  and  sometimes 
too  slowly.  The  readiest  mode  of  obtaining  what 
is  desired,  is  for  the  examiner  to  illustrate  it  by  his 
own  breathing.  A  complete  expiration  is  important 
in  order  to  secure  a  satisfactory  inspiration.  It 
should,  therefore,  be  made  clear  by  explanation  and 
illustration,  that  each  expiration  should  be  finished 
before  the  following  inspiration.  Breathing  through 
Dr.  E.  Holden's  "  Kesonator,"  a  flexible  tube  of  con- 
siderable size,  with  a  mouth-piece,  secures  the  re- 
quisite force  of  the  respiratory  acts,  and  is  in  this 
way  useful.     (Fig.  10.) 

The  ability  to  abstract  the  mind  from  thoughts 
and  other  sounds  than  those  to  which  the  attention 


AUSCULTATION    IN    HEALTH. 


81 


is  to  be  directed,  is  essential  to  success  in  ausculta- 
tion. All  persons  do  not  possess  equally  this  ability, 
and  herein  is  an  explanation  in  part  of  the  fact  that 
all  are  not  alike  successful.  To  develop  and  culti- 
vate by  practice  the  power  of  concentration,  is  an 
object  which  the  student  should  keep  in  view. 
Generally,  at  first,  complete  stillness  in  the  room  is 

Fig.  10. 


Bolden'e  Resonator. 


indispensable  for  the  study  of  auscultatory  sounds ; 
with  practice,  however,  in  concentrating  the  atten- 
tion, this  becomes  less  and  less  essential. 


The  study  of  auscultation  in  health  embraces  the 
following  : 

1.  The  sounds  produced  by  respiration  as  heard 
<>vcr  the  larynx  and  trachea,  or  the  normal  laryngeal 
ami  tracheal  respiration. 

2.  The  sounds  heard  over  the  chest  in  tin'  acts 
<>!'  respiration.  These  sounds,  coming  chiefly  from 
the  air- vesicles,  constitute  whal  is  called  the  normal 
vesicular  murmur. 

3.  The  resonance  heard  over  the  chest,  and  the 
vibration  or  thrill  produced  by  the  loud  voice,  or 
the  normal  vocal  resonance  and  fremitus. 


82  AUSCULTATION    IN    HEALTH. 

4.  The  sounds  heard  over  the  chest  with  the 
whispered  voice,  or,  inasmuch  as  these  sounds  are 
conducted  chiefly  by  the  air  in  the  bronchial  tubes, 
the  normal  bronchial  whisper. 

These  four  normal  signs  will  be  considered  in  the 
foregoing  order. 

Normal  Laryngeal  and  Tracheal  Respiration. 

For  all  practical  purposes  the  laryngeal  and  the 
tracheal  respiration  may  be  considered  to  be  iden- 
tical, that  is,  the  shades  of  difference  between  the 
sounds  in  these  two  situations  are  not  of  importance 
as  regards  the  application  to  physical  diagnosis. 
The  laryngeal  respiration  is  more  readily  studied 
than  the  tracheal,  and  for  the  study  of  both  the 
stethoscope  is  necessary. 

Applying  the  stethoscope  over  the  side  of  the 
larynx,  the  person  examined  breathing  with  some 
increase  of  force,  but  without  any  alteration  in 
rhythm,  a  sound  is  heard  with  each  of  the  two  acts 
of  respiration.  The  inspiratory  and  the  expiratory 
sound,  studied  separately  and  contrasted  with  each 
other,  have  the  following  characters  relating  to  in- 
tensity, pitch,  quality,  duration,  and  rhythm:  The 
inspiratory  sound  is  of  variable  intensity.  In  ordi- 
nary breathing  it  varies  much  in  different  persons, 
and  in  different  acts  of  breathing  in  the  same  person. 
It  is  always  considerably  intense  in  forced  breathing. 
The  pitch  is  high  when  compared  with  the  inspira- 
tory sound  as  heard  over  the  chest.  The  quality  of 
the  sound  is  well  defined  bv  the  word  tubular;-  the 


NORMAL    LARYNGEAL    RESPIRATION.         83 

sound  at  once  suggests  a  current  of  air  through  a 
tube.  The  duration  of  the  sound  is  from  the  begin- 
ning  to  nearly,  not  quite,  the  end  of  the  inspiratory 
act.  The  characters  of  the  inspiratory  sound,  thus, 
are  more  or  less  intensity,  a  high  pitch,  a  tubular 
quality,  and  a  duration  a  little  less  than  that  of  the 
act  of  inspiration. 

An  expiratory  sound  is  always  heard  with  forced 
breathing.  As  regards  duration,  it  is  as  long  as,  or 
longer  than,  the  sound  of  inspiration.  In  general  it 
is  more  intense  than  the  sound  of  inspiration.  The 
pitch  is  higher  than  that  of  the  inspiratory  sound. 
The  quality  is  the  same  as  that  of  the  inspiratory 
sound,  namely,  tubular. 

Repeating  the  characters  distinctive  of  the  normal 
laryngeal  respiration,  they  are  as  follows:  The  in- 
spiratory sound  is  of  variable  intensity,  high  in 
pitch,  and  tubular  in  quality.  The  expiratory  sound 
i-  as  long  as,  or  longer  than,  the  inspiratory  sound  : 
it  is  higher  in  pitch,  and  usually  more  intense. 
Owing  to  the  inspiratory  sound  nol  continuing 
quite  to  the  end  of  the  inspiratory  art,  there  is  a 
very  short  interval  between  the  two  sounds.  In 
this  latter  point  consists  the  only  variation  between 
the  rhythm  of  the  acts  of  breathing  and  that  of  the 
Bounds. 

The  foregoing  characters  Bhould  not  only  be 
verified  by  Hi"  Btudent,  but  he  should  become 
familiar  with  them  by  practice  that  it  requires  no 
efforl  of  the  mind  to  recoiled  them.  It  will  he  seen 
hereafter  that  these  characters  of  the  normal  laryn- 
geal respiration  are  precisely  those  which  distinguish 


84  AUSCULTATION    IN    HEALTH. 

an  important  morbid  physical  sign,  namely-  the  bron- 
chial or  tubular  respiration. 

Normal  Vesicular  Murmur. 

This  is  the  name  usually  given  to  the  respiratory 
sounds  heard  over  the  different  regions  of  the  chest. 
These  sounds  should  be  studied  with  the  ear  applied 
directly  to  the  chest  (immediate  auscultation),  as 
well  as  with  the  stethoscope.  In  commencing  the 
study,  the  middle  of  the  anterior  surface  of  the  chest 
on  the  right  side,  to  avoid  the  sounds  of  the  heart, 
or  still  better,  the  posterior  aspect  belowT  the  scapula 
on  either  side,  should  be  selected.  The  person  ex- 
amined should  breathe  somewhat  more  forcibly  than 
in  ordinary  breathing,  but  not  violently  nor  quickly, 
nor  too  slowly,  the  normal  rhythm  being  unchanged. 
Children  are  better  than  adults  for  this  study,  owing 
to  the  greater  intensity  of  the  murmur  in  early  life. 

The  characters  which  belong  to  the  inspiratory 
and  the  expiratory  sound  in  the  normal  vesicular 
murmur  are  as  follows :  The  inspiratory  sound  is  of 
variable  intensity.  There  is  a  wide  variation  in  dif- 
ferent healthy  persons.  In  some  persons  it  is  so 
feeble  as  scarcely  to  be  appreciable  even  with  the 
binaural  stethoscope.  The  pitch  of  the  sound,  com- 
pared with  the  inspiratory  sound  in  the  normal 
laryngeal  or  tracheal  respiration,  is  notably  low. 
The  quality  of  the  sound  is  peculiar;  no  distinct 
idea  of  the  quality  can  be  formed  by  any  comparison. 
The  name  used  to  designate  the  quality  is  vesicular, 
this  name  only  denoting  that  the  air-vesicles  are  in 
some  way  concerned  in  the  production  of  the  sound. 
This  vesicular  quality  must  be  impressed  upon  the 


NORMAL    VESICULAR    MURMUR.  85 

perception  and  memory  by  direct  observation.  The 
duration  of  the  inspiratory  sound  is  from  the  begin- 
ning to  the  end  of  the  inspiratory  act. 

An  expiratory  sound  is  not  always,  although  gener- 
ally, appreciable.  It  is  much  less  intense  than  the 
sound  of  inspiration.  It  is  notably  lower  in  pitch 
than  the  sound  of  inspiration.  The  quality  of  the 
sound  is  neither  vesicular  nor  tubular.  It  may  be 
called  simply  a  blowing  sound,  and  may  be  imitated 
by  blowing  with  the  mouth  partially  opened.  The 
duration  is  much  shorter  than  that  of  the  inspira- 
tory sound. 

The  characters,  thus,  which  distinguish  the  normal 
vesicular  murmur  are,  an  inspiratory  sound  variable 
in  intensity,  low  in  pitch,  and  vesicular  in  quality; 
an  expiratory  sound  less  intense  than  the  inspira- 
tory, still  lower  in  pitch,  non-vesicular  and  non- 
tubular,  or  simply  blowing;  the  inspiratory  sound 
continuing  from  the  beginning  to  the  end  of  the  in- 
spiratory act,  and  the  expiratory  sound  beginning 
with  the  expiratory  act  but  ending  before  this  act  is 
completed,  its  duration,  relatively  to  the  inspiratory 
sound,  being  variable,  but  averaging  about  a  fifth. 
The  inspiratory  sound  continuing  to  the  end  of  in- 
spiration, and  the  expiratory  sound  beginning  with 
the  acl  of  expiration,  it  follows  thai  there  is  no  in- 
terval between  the  two  sounds.  It  is  to  be  remarked 
that  an  interval  is  not  infrequently  produced  by  the 
person  examined  holding  the  breath  after  inspira- 
tion i>  completed.  'This  variation  in  the  rhythm  of 
the  acts,  of  course,  produces  a  corresponding  varia- 
tion in  Bounds  of  breathing. 

The  characters  of  the  normal  vesicular  respiration 


86  AUSCULTATION    IN    HEALTH. 

may  be  studied  by  inflating  the  lungs  removed  from 
the  human  cadaver,  or  from  the  sheep  or  calf,  and 
applying  the  binaural  stethoscope  directly  upon  the 
pulmonary  surface.  In  this  experiment  the  vesic- 
cular  quality  is  strongly  marked.  In  the  same  way 
the  tracheal  respiration  may  be  studied  and  its 
characters  contrasted  with  those  of  the  vesicular 
respiration.  It  is  recommended  to  the  student  to 
resort  to  this  readily  available  method  to  study  the 
normal  respiratory  signs. 

Having  become  familiar  with  the  characters  of 
the  normal  vesicular  respiration  as  compared  with 
those  of  the  normal  laryngeal  or  tracheal  respira- 
tion, the  student  may  then  proceed  to  study  the 
former  in  the  different  regions  of  the  chest.  The 
murmur  will  be  found  to  present  variations  in  the 
different  regions  on  the  same  side,  and  in  the  corre- 
sponding regions  on  the  two  sides  of  the  chest. 
The  variations,  within  the  range  of  health,  in  the 
latter  are  especially  important.  The  following  ac- 
count of  the  murmur  in  the  different  regions 
embodies  the  results  of  the  analysis  of  a  series  of 
recorded  examinations  of  healthy  persons.1 

Right  and  Left  Infra-clavicular  Region. — The  mur- 
mur in  this  region,  on  either  side,  differs  more  or 
less  from  the  murmur  as  heard  in  the  anterior  re- 
gions below,  or  in  the  infra-scapular  region.  The 
vesicular  quality  in  the  inspiration  is  less  marked. 
The  pitch  is  higher.  The  expiratory  sound  is  longer, 
less  feeble,  and  higher  in  pitch.     The  difference  be- 

1  Vide  Prize  Essay,  Transact.  Am.   Med.  Association,  Vol.  V., 
1852. 


NORMAL    VESICULAR    MURMUR.  87 

tween  the  two  sides  in  this  region  is  especially  im- 
portant with  reference  to  diagnosis.  The  intensity 
of  the  inspiratory  sound  is  almost  invariably  greater 
on  the  left  side.  Its  vesicular  quality  is  more 
marked,  and  the  pitch  is  lower.  Per  contra,  the 
inspiratory  sound  on  the  right  side,  in  this  region, 
is  less  intense,  less  vesicular,  and  higher  in  pitch 
than  the  inspiratory  sound  on  the  left  side.  In 
forced  breathing  the  intensity  of  the  murmur  is  in- 
creased more  on  the  left  than  on  the  right  side. 
The  expiratory  sound  is  sometimes  wanting  on  the 
left,  when  it  is  heard  on  the  right  side.  On  the 
right  side,  the  expiratory  sound  is  longer  than  on 
the  left  side.  It  may  be  prolonged  on  the  right 
side  to  nearly  or  quite  the  length  of  the  inspiratory 
sound.  Sometimes  on  the  right  side  the  pitch  of  the 
expiratory  is  higher  than  that  of  the  inspiratory  on 
tin'  same  Bide,  and  it  may  have  a  tubular  quality. 
A  rare  peculiarity  is  a  prolonged,  high,  tubular  ex- 
piratory sound  on  both  sides,  analogous  to  the 
laryngeal  or  tracheal  expiration.  When  this  is  the 
ease,  the  pitch  of  the  expiratory  sound  is  higher  on 
the  left  than  on  the  right  side. 

These  several  modifications  of  the  respiratory 
murmur  in  the  infra-clavicular  region  are  marked 
in  proportion  as  the  sounds  are  Btudied  Dear  the 
-termini,  that  i-,  over  the  site  of  the  primary 
bronchi.  The  respiratory  murmur  in  this  situa- 
tion has  been  called  the  uorraal  bronchial  respira- 
tion, from  its  resemblance  ti>  the  morbid  sign  so 
named.  It  may  he  more  properly  called  a  vesiculo- 
tubular,  <>r  the  normal  broncho-vesicular  respira- 
tion, the  characters  being  those  of  the  morbid  Bign 


88  AUSCULTATION    IN    HEALTH. 

which,  under  the  latter  name,  will  be  described  in 
the  next  chapter. 

In  the  diagnosis  of  diseases,  especially  of  phthisis, 
due  allowance  must  be  made  for  the  points  of  dis- 
parity which  exist  normally  between  the  two  sides 
of  the  chest  in  the  infra-clavicular  region.  Without 
a  practical  knowledge  of  these  points  of  disparity, 
error  in  diagnosis  can  hardly  be  avoided. 

Bight  and  Left  Scapular  Region. — As  compared 
with  the  infra-clavicular  region,  the  respiratory 
murmur  heard  over  the  scapula  on  either  side  is 
feeble,  and  the  vesicular  quality  is  less  marked. 
The  inspiratory  sound  is  generally  weaker  and  the 
pitch  higher  on  the  right  than  on  the  left  side. 
The  expiratory  sound  is  more  constantly  heard  on 
the  right  than  on  the  left  side.  It  may  be  prolonged 
on  the  right  side,  and  is  sometimes  higher  in  pitch 
than  the  inspiratory  sound.  Compared  with  the 
left  side,  the  murmur  on  the  right,  in  this  region, 
thus  may  have  vesiculo-tubular  or  broncho-vesicular 
characters  more  or  less  marked. 

Right  and  Left  Inter-scapular  Region. — In  the  upper 
and  middle  portions  of  this  region,  the  normal  char- 
acters are  the  same  as  in  the  sterno-clavicular  portion 
of  the  infra-clavicular  region.  The  same  points  of 
disparity  between  the  two  sides  are  more  or  less 
marked  here  as  they  are  anteriorly  over  the  site  of 
the  primary  bronchi. 

Right  and  Left  Infra-scapular  Region. — The  inten- 
sity of  the  murmur  is  greater  than  over  the  scapular 
region.  In  most  persons  there  is  no  notable  disparity 
between  the  two  sides ;  when  a  disparity  exists,  the 
intensity  is  greater  and  the  pitch  lower  on  the  left 


NORMAL    VOCAL    RESONANCE.  89 

side.  A  prolonged,  high-pitched,  bronchial  expi- 
ratory sound  is  sometimes  transmitted  below  the 
scapula  on  the  right  side. 

Bight  and  Left  Mammary  and  Infra- ma  mi  nary  Re- 
gions.— The  inspiratory  sound  in  these  regions  is  less 
intense  than  in  the  infra-clavicular  region  ;  the  vesic- 
ular quality  is  more  marked,  and  the  pitch  is  lower. 
An  expiratory  sound  is  often  wanting. 

Bight  and  Left  Axillary  and  Infra-axillary  Regions. 
— The  inspiratory  sound  in  these  regions  is  as  in- 
tense as  in  any  portion  of  the  chest.  The  intensity 
is  less  in  the  infra-axillary  than  in  the  axillary  re- 
gion, and  the  pitch  is  lower.  In  some  persons  the 
murmur  on  the  two  sides  presents  no  disparity,  but 
in  other  persons  the  vesicular  quality  is  somewhat 
more  marked  and  the  pitch  is  lower  on  the  left  than 
on  the  right  side.  An  expiratory  sound  is  oftener 
heard  than  in  the  mammary  and  infra-mammary 
regions. 

Normal  Vocal  Resonance. 

Laryngeal  and  Tracheal  Voice. — It  will  prepare  the 
student  for  the  appreciation  of  the  distinctive  char- 
acters of  the  morbid  signs  pertaining  to  the  voice, 
to  study  the  vocal  signs  over  the  larynx  and  trachea. 
Applying  the  stethoscope  either  over  the  broad  sur- 
face  of  the  thyroid  cartilage,  or  just  above  the  sternal 
notch,  and  requesting  the  person  examined  to  count 
with  a  moderate  intensity  of  voice,  the  anscnltator 
perceives  a  strong  resonance,  with  a  sensation  <>f 
concussion  or  shock,  ami  a  lense  of  vibration,  thrill, 
or  fremitus.  The  roice  seems  to  he  concentrated 
and  near  the  ear.     Sometimes  the  articulated  words 

8* 


90  AUSCULTATION    IN    HEALTH. 

are  transmitted  so  as  to  be  heard  more  or  less  dis- 
tinctly. The  laryngeal  or  tracheal  voice  thus  (laryn- 
gophony,  tracheophony)  embraces  different  elements, 
namely,  1st,  the  vocal  resonance;  2d,  the  concen- 
tration and  nearness  to  the  ear;  3d,  the  vibration, 
thrill,  or  fremitus;  and  4th,  the  transmission  of  the 
speech,  the  latter  corresponding  to  pectoriloquy. 
These  different  elements  will  be  found  to  enter  into 
the  distinctive  characters  of  morbid  vocal  signs. 

The  sounds  heard  over  the  larynx  and  trachea 
when  words  are  spoken  in  a  whisper  should  be 
studied,  inasmuch  as  important  morbid  signs  relate 
to  the  whispered  voice.  Whispered  words  occasion 
little  or  no  shock  or  thrill,  but  an  intense,  high- 
pitched  tubular  sound,  with  a  sensation  as  if  a  cur- 
rent of  air  were  directed  into  the  ear  through  the 
stethoscope.  This  sound  corresponds  to  the  sound 
of  expiration  in  laryngeal  or  tracheal  respiration ; 
the  two  sounds  are,  in  fact,  identical  if,  as  is  the 
case  with  some  exceptions,  the  person  whisper  with 
the  expiratory  breath.  Articulated  words  are 
transmitted  with  more  or  less  distinctness,  thus 
corresponding  with  the  morbid  sign  called  whisper- 
ing pectoriloquy. 

Normal  Thoracic  Vocal  Resonance  and  Fremitus. — 
The  vocal  resonance  over  the  chest  is  to  be  studied 
both  by  means  of  the  stethoscope  and  by  immediate 
auscultation.  When  the  latter  is  employed  the  ear 
not  applied  to  the  chest  should  be  closed  in  order 
to  exclude  the  entrance  of  sound  from  the  mouth  of 
the  person  examined.  When  the  stethoscope  is  em- 
ployed, care  must  be  taken,  in  making  a  comparison 
between  the  two  sides  of  the  chest,  or  between  dif- 


NORMAL    VOCAL    RESONANCE.  91 

ferent  regions  on  the  same  side,  that  the  pectoral 
extremity  of  the  instrument  be  pressed  with  an 
equal  amount  of  force  against  the  chest.  The  in- 
tensity with  which  the  vocal  resonance  is  transmitted 
is  much  affected  by  the  degree  of  pressure  with  the 
stethoscope. 

The  situations  in  which  the  student  should  com- 
mence the  study  of  the  normal  vocal  resonance  are 
those  selected  for  beginning  the  study  of  the  normal 
vesicular  murmur,  namely,  the  middle  of  the  anterior 
aspect  of  the  chest  on  the  right  side,  and  below  the 
scapula  behind. 

With  the  stethoscope  or  the  ear  directly  applied 
in  the  situations  just  named,  the  person  examined 
should  be  requested  to  count  one,  two,  three,  in  a 
uniform  tone,  and  with  moderate  force.  The  ex- 
aminer should  himself  pronounce  these  numerals, 
in  order  to  show  the  manner  of  counting.  This  is 
far  better  than  asking  a  question  and  studying  the 
resonance  during  the  answer  of  the  person  examined. 
The  objection  to  the  latter  mode  is,  the  attention  of 
the  examiner  is  divided  between  the  characters  of 
the  thoracic  resonance  and  the  idea  conveyed  by 
the  answer.  The  characters  of  the  vocal  resonance 
in  these  situations  arc  as  follows: 

The  voice  [a  heard  with  an  intensity  which  varies 
very  much  in  different  persons;  in  some  the  reso- 
nance is  feeble,  and  it  may  be  almost  inappreciable, 
while  in  others  it  is  quite  intense.  The  intensity 
depends  greatly  on  the  loudness  and  lowness  in 
pitch  of  the  voice  of  the  person  examined.  The 
resonance  is  notably  weaker  in  women  than  in  men. 
It  is  rarely  attended  with  a  sense  of  concussion  or 


92  AUSCULTATION    IN    HEALTH. 

shock.  It  is  diffused;  that  is,  it  does  not  seem  to 
be  concentrated  like  the  tracheal  or  laryngeal  vocal 
resonance.  It  evidently  comes  from  a  certain  dis- 
tance; that  is,  the  sound  does  not  seem  to  be 
near  the  ear.  Impression  of  the  distance  of  the 
sound  is  highly  distinctive  of  the  normal  reson- 
ance as  compared  with  a  morbid  vocal  sign  (bron- 
chophony). The  resonance  is  accompanied  by  a 
sense  of  vibration,  thrill,  or  fremitus,  the  intensity 
of  which,  like  the  resonance,  varies  much  in  dif- 
ferent persons.  This  fremitus  is  properly  not  an 
acoustic  but  a  tactile  sign.  The  normal  vocal  fre- 
mitus, together  with  its  abnormal  modifications,  be- 
long to  the  method  of  physical  exploration  called 
palpation.  It  is,  however,  appreciated  by  the  ear  as 
well  as  by  the  touch,  and  may  be  studied  in  the 
practice  of  auscultation.  The  student  should  prac- 
tically distinguish  from  each  other,  and  study  sepa- 
rately, the  vocal  resonance  and  vocal  fremitus. 

From  the  foregoing  characters  the  normal  vocal 
resonance  may  be  defined  as,  diffused,  distant,  vari- 
able in  intensity,  and  accompanied  with  more  or  less 
vibration,  thrill,  or  fremitus. 

Having  become  practically  familiar  with  these 
characters  of  the  normal  vocal  resonance  in  the 
situations  in  which  they  are  first  to  be  studied,  the 
next  object  of  study  relates  to  the  normal  variations 
in  the  different  regions  on  the  same  side  of  the 
chest,  and  in  corresponding  regions  on  the  two 
sides.  In  giving  an  account  of  these  variations, 
based  on  a  series  of  recorded  examinations  in 
healthy  persons,  the  different  regions  will  be  con- 


NORMAL    VOCAL    RESONANCE.  93 

sidered  in  the  same  order  as  in  the  study  of  the  vari- 
tions  of  the  respiratory  sounds  {vide  p.  86  et  seq.). 

Infra-cladcular  Region. — The  vocal  resonance  in 
this  region  on  either  side  is  more  intense  than  in 
the  anterior  regions  below,  the  intensity,  however, 
in  different  persons  being  very  variable.  Irrespec- 
tive of  intensity,  it  is  less  diffused  nearer  the  ear, 
and  the  pitch  is  somewhat  higher.  These  latter 
variations  are  marked  chiefly  in  the  sterno-clavic- 
ular  extremity  of  the  region,  that  is,  over  the  site  of 
the  primary  bronchi.  In  sonic  persons  the  concen- 
tration, nearness  to  the  ear  and  elevation  of  pitch, 
especially  on  the  right  side,  are  such  as  to  approxi- 
mate the  normal  resonance  to  the  morbid  sign  called 
bronchophony.  The  characters  of  this  sign  will  be 
considered  in  the  next  chapter,  but  it  is  important 
to  know  that  exceptionally  these  characters  may  be, 
in  a  measure,  illustrated  in  health  in  the  infra-clavic- 
ular region.  The  resonance  may  then  be  termed 
normal  bronchophony. 

A  comparison  of  the  resonance  in  the  region  on 
the  right  side  and  on  the  left  side  always  shows  a 
disparity.  The  resonance  on  the  right  side  is  in- 
variably greater.  The  degree  of  difference  between 
the  two  sides  varies  in  different  persons.  The  reso- 
nance may  be  more  or  less  marked  on  the  right  and 
nearly  wanting  on  the  left  side.  Allowance  is  to 
be  made  for  the  points  of  normal  disparity  between 
the  two  sides  in  the  diagnosis  of  disease  ;  hence  the 
student  must  become  practically  familiar  with  them. 

The  vocal  vibration  or  fremitus  varies  fully  as 
much  as  the  vocal  resonance  in  different  person-. 
It-   intensity  is  not   always  proportionate  to  that  of 


94  AUSCULTATION    IN    HEALTH. 

the  resonance ;  that  is,  the  resonance  may  be  com- 
paratively weak  when  the  fremitus  is  strong,  and 
vice  versa.  The  fremitus,  like  the  resonance,  is 
always  greater  on  the  right  than  on  the  left  side, 
the  disparity,  like  that  of  the  resonance,  varying 
considerably  in  different  persons. 

Scapular  Region. — The  resonance  in  this  region  is 
notably  less  intense  than  in  the  infra-clavicular  re- 
gion. It  is  also  more  diffused  and  distant.  The 
intensity  is  always  greater  on  the  right  side.  These 
statements  are  alike  applicable  to  the  vocal  fremitus. 

Inter-scapular  Region. — The  intensity  of  the  reso- 
nance here  is  nearly  or  quite  as  great  as  in  the 
sterno-clavicular  extremity  of  the  infra-clavicular 
region.  The  resonance  has  in  some  persons  in  this 
region  the  characters  of  bronchophony.  The  in- 
tensity is  always  greater  on  the  right  side.  The 
fremitus  is  more  or  less  marked,  and  always  more 
marked  on  the  right  than  on  the  left  side. 

Infra- scapular  Region. — As  a  rule,  the  resonance 
in  this  region  is  stronger  than  over  the  scapula.  It 
is  always  characterized  by  diffusion  and  distance. 
As  in  all  the  regions,  it  varies  much  in  different 
persons,  and  is  stronger  on  the  right  than  on  the 
left  side.  These  statements  are  also  applicable  to 
fremitus. 

Mammary  and  Infra-mammary  Regions. — The  reso- 
nance is  notably  less  than  at  the  summit  of  the  chest. 
The  characters  of  bronchophony  are  never  present. 
The  intensity  is  greater  on  the  right  side.  The 
same  is  true  of  fremitus. 

Axillary  and  Infra-axillary  Regions. — The  resonance 
in  these  regions,  and  especially  in  the  axillary  region, 


NORMAL    BRONCHIAL    WHISPER.  95 

is  greater  than  over  the  mammary  and  infra- mam- 
mary regions.  It  is,  of  course,  stronger  on  the  right 
side.  The  characters  as  contrasted  with  those  of 
bronchophony,  namely,  distance  and  diffusion,  are 
marked.  Fremitus  is  more  or  less  marked,  and,  of 
course,  more  marked  on  the  right  than  on  the  left 
side. 

Normal  Bronchial  Whisper. 

Prior  to  the  publication  of  the  author's  work  on 
the  "  Physical  Exploration  of  the  Chest,"  in  1856, 
signs  in  health  and  disease  relating  to  the  whispered 
voice  had  received  but  little  attention.  In  that  work, 
and  more  fully  in  the  second  edition,  published  in 
1866,  a  series  of  signs  accompanying  whispered 
words  were  described  and  named.  As  a  point  of 
departure  for  the  study  of  the  morbid  signs  thus 
obtained,  of  course  the  signs  in  health  must  first  be 
studied.  The  sounds  which  are  heard  over  different 
parts  of  the  chest  in  health  I  have  embraced  under 
the  name,  the  normal  bronchial  whisper.  The  per- 
tinency of  this  name  is  derived  from  the  fact  that  the 
conduction  of  the  sound  produced  by  the  whispered 
voice  must  be  chiefly  by  the  air  contained  in  the 
bronchial  tubes.  The  sound  heard  over  the  trachea 
and  larynx  may  be  distinguished  as  the  laryngeal  or 
tracheal  whisper,  the  characters  of  which  have  been 

already  stated  [vide  page  90). 

It  will  facilitate  the  st udy  of  the  normal  bronchial 
whisper,  as  well  as  of  the  morbid  signs,  to   consider 

that  the  characters  of  the  sounds  produced  with  the 
whispered  voice  are  identical  with  those  produced 
by  the  ac1  of  expiration  in  all  respects  save  intensity. 


96  AUSCULTATION    IN    HEALTH. 

Whispered  words  are  produced,  as  a  rule,  by  an  act 
of  expiration,  the  sounds  being  more  intense  gen- 
erally than  those  which  accompany  even  forced 
breathing.  Curiously  enough,  there  are  exceptions 
to  this  rule.  Some  persons  insist  upon  whispering 
with  the  act  of  inspiration,  and  there  are  some  per- 
sons who  have  never  acquired  the  ability  to  whisper. 
It  will  be  at  once  evident  that  the  pitch  and  quality 
of  sounds  produced  by  whispered  words  with  the 
act  of  expiration,  must  be  the  same  as  those  of  the 
sounds  of  expiration  in  breathing. 

Selecting  for  the  study  of  the  normal  bronchial 
whisper  the  same  situations  as  in  commencing  the 
study  of  the  normal  respiratory  murmur,  and  the 
normal  vocal  resonance,  namely,  the  middle  of  the 
chest  in  front,  on  the  right  side,  and  the  infra- 
scapular  region  behind,  with  the  whispered  voice  in 
these  situations  is  heard,  in  most  persons,  a  feeble, 
low-pitched  blowing  sound,  these  characters  corre- 
sponding to  those  of  the  expiratory  sound  in  forced 
breathing.  The  normal  bronchial  whisper  in  these 
situations  is  not  in  all  persons  appreciable. 

In  the  infra-clavicular  region,  the  bronchial  whisper 
is  heard,  with  variable  intensity,  in  most  persons.  It 
is  somewhat  higher  in  pitch  than  the  whisper  below 
this  region.  It  is  louder  and  higher  in  the  sterno- 
clavicular than  in  the  acromial  extremity.  In  the 
former  situation  it  has  not  infrequently  a  tubular 
quality.  It  is  louder  on  the  right  than  on  the  left 
side  of  the  chest.  It  is  sometimes  heard  on  the  right 
when  it  is  inappreciable  on  the  left  side.  When 
heard  on  both  sides  the  pitch  of  the  sound  is  higher 
on  the  left  than  on  the  right  side.     It  will  be  ob- 


NORMAL    BRONCHIAL    WHISPER.  97 

served  that  these  variations  correspond  to  those  of 
the  sound  with  expiration  in  the  infra-clavicular 
region  (vale  page  86).  Occasionally  whispered  words 
are  partly  transmitted,  constituting  incomplete  whis- 
pering pectoriloquy. 

In  the  scapular  region  the  bronchial  whisper  is 
not  infrequently  wanting.  It  may  be  present  on  the 
right  and  not  on  the  left  side,  and  if  present  on  both 
sides,  it  is  always  louder  on  the  right  side. 

In  the  inter-scapular  region,  as  a  rule,  it  is  nearly 
or  quite  as  marked  as  over  the  site  of  the  primary 
bronchi  in  front.  The  pitch  is  more  or  less  high, 
and  has  a  tubular  quality.  It  is  louder  on  the  right 
and  higher  in  pitch  on  the  left  side,  and  in  this 
situation  there  may  be  incomplete  pectoriloquy. 

In  the  infra-scapular  region,  it  is  not  infrequently 
wanting.  When  present  it  is  generally  feeble,  the 
pitch  being  low  and  the  quality  non-tubular,  or 
blowing.  It  is  oftener  wanting  on  the  left  than  on 
the  right  side,  and,  if  present  on  both  sides,  it  is 
louder  on  the  right  side. 

In  the  mammary  and  infra-mammary  regions  it  is 
not  infrequently  wanting,  and  the  statements  just 
made  with  reference  to  the  infra-scapular  region  are 
alike  applicable  to  these,  as,  also,  to  the  axillary  and 
infra-axillary  regions. 


CHAPTER  V. 

AUSCULTATION  IN  DISEASE. 

The  respiratory  signs  of  Disease  : — Abnormal  modifications  of  the  normal 
respiratory  sounds  : — Increased  vesicular  murmur — Diminished  vesic- 
ular murmur — Suppressed  respiratory  sound — Bronchial  or  tubular 
respiration — Broncho- vesicular  respiration — Cavernous  respiration — 
Broncho-cavernous  respiration  —  Vesiculo-  cavernous  respiration  — 
Amphoric  respiration — Shortened  inspiration — Prolonged  expiration — 
Interrupted  respiration.  Adventitious  respiratory  sounds  or  rales. 
Laryngeal  or  tracheal  rales — Moist  bronchial  rales,  coarse,  fine,  and 
subcrepitant — Vesicular  or  crepitant  rale — Cavernous  or  gurgling  rale 
— Pleural  friction  rales,  metallic  tinkling  and  splashing — Indeterminate 
rales.  The  vocal  signs  of  disease:  Bronchophony — Whispering  bron- 
chophony-— iEgophony — Increased  vocal  resonance — Increased  bron- 
chial whisper — Cavernous  whisper — Pectoriloquy — Amphoric  voice  or 
echo — Diminished  and  suppressed  vocal  resonance — Diminished  and 
suppressed  vocal  fremitus — Metallic  tinkling.  Signs  obtained  by  acts 
of  coughing  or  tussive  sounds. 

The  importance  of  becoming  perfectly  familiar 
with  the  signs  of  health  before  entering  upon  the 
study  of  morbid  signs,  cannot  be  too  strongly  en- 
forced. The  auscultatory  signs  of  disease,  which 
are  to  be  considered  in  this  chapter,  should  not  be 
studied  until  the  student  has  made  himself  complete 
master  of  all  the  characters  belonging  to  the  normal 
signs  obtained  by  auscultation. 

Auscultation  in  disease  embraces  the  signs  pro- 
duced by  respiration,  by  the  voice,  and  by  acts  of 
coughing.  The  respiratory  signs  will  be  first  con- 
sidered. 


MODIFICATIONS    OF   NORMAL   SOUNDS.       99 

The  Respiratory  Signs  of  Disease. 

The  morbid  signs  produced  by  respiration  may  be 
classified  as  follows:  1st.  Those  which  are  abnormal 
modifications  of  the  normal  respiratory  sounds.  2d. 
Those  which  have  no  analogues  in  health,  being 
entirely  new  or  adventitious  sounds.  The  latter  are 
usually  embraced  under  the  name  relies. 

Abnormal  Modifications  of  the  Normal  Respiratory 
Sounds. 

In  order  to  appreciate  the  distinctive  characters 
of  the  signs  embraced  in  this  class,  the  characters 
which  distinguish  the  normal  vesicular  murmur  must 
be  kept  in  mind.  The  abnormal  modifications  which 
characterize  these  morbid  signs  relate  to  intensity, 
pitch,  and  quality  of  sound,  together  with  certain 
alterations  in  rhythm.  Twelve  signs  are  included 
under  this  heading,  namely:  1.  Increased  vesicular 
murmur;  2.  Diminished  vesicular  murmur;  3.  Sup- 
pression of  respiratory  sound;  4.  Bronchial  or  tubu- 
lar respiration:  5.  Broncho-vesicular  respiration;  6. 
Cavernous  respiration;  7.  Broncho-cavernous  respi- 
ration; 8.  Vesiculo-cavernona  respiration;  9.  Am- 
phoric respiration;  10.  Shortened  inspiration;  11. 
Prolonged  expiration;  and,  12.  Interrupted  inspi- 
ration. 

The8e  3igne  arc  to  be  studied,  first,  with  reference 
to  their  distinctive  characters  severally,  each  being 
contrasted,  as  respects  these  characters,  with  the 
other  morbid  respiratory  signs  as  well  as  with  the 
Dormal  vesicular  murmur;  and,  Becond,  with  refer- 


100  AUSCULTATION    IN    DISEASE. 

ence  to  the  morbid  physical  conditions  which  they 
severally  represent,  that  is,  the  diagnostic  signifi- 
cance which  belongs  to  each. 

Increased  Vesicular  Murmur. — This  sign  has  but  a 
single  distinctive  character,  namely,  increase  of  in- 
tensity. The  murmur  is  abnormally  loud,  the  char- 
acters of  the  normal  vesicular  murmur  being  in  other 
respects  not  materially  changed,  that  is,  the  pitch  is 
low  and  the  quality  vesicular  as  in  health.  Now,  it 
has  been  seen  {vide  page  85)  that  the  intensity  of  the 
healthy  murmur  varies  much  in  different  persons; 
there  is  no  ideal  standard  of  normal  intensity  by 
reference  to  which  an  abnormal  increase  is  to  be 
determined.  Yet  the  increase  under  certain  condi- 
tions of  disease  is  such  that  the  fact  is  sufficiently 
evident.  It  occurs  on  the  healthy  side  of  the  chest 
when  the  respiratory  function  on  the  other  side  is 
annulled  or  much  compromised  by  disease.  This 
takes  place  in  cases  of  pleurisy  with  large  effusion, 
pneumonia,  especially  if  more  than  one  lobe  be  af- 
fected, obstruction  of  one  of  the  primary  bronchi, 
and  pneumothorax.  The  sign  does  not  possess 
great  diagnostic  importance  inasmuch  as  the  nature 
and  extent  of  the  disease  are  ascertained  by  the  signs 
obtained  on  the  affected  side. 

The  sign  has  been  called  supplementary  and  puerile 
respiration. 

If  the  murmur  be  much  intensified,  it  may  possibly 
be  mistaken  for  other  morbid  signs,  namely,  bron- 
chial or  broncho-vesicular  respiration.  This  error, 
however,  can  never  be  made  if  the  distinctive  char- 
acters of  these  signs  relating  to  pitch  and  quality 
have  been  correctly  studied. 


MODIFICATIONS    OF    NORMAL   SOUNDS.      101 

Diminished  Vesicular  Murmur. — The  intensity  of 
the  vesicular  murmur  may  be  on  the  one  hand  di- 
minished when  it  is  evident  that  in  other  respects 
there  is  no  material  change,  and  the  murmur,  on 
the  other  hand,  may  become  so  feeble  that  characters 
aside  from  the  intensity  are  not  determinable.  From 
the  latter  fact  it  follows  that  the  murmur  must  some- 
times be  considered  as  only  weakened,  when,  were 
the  diminished  intensity  not  as  great,  morbid  changes 
in  pitch  and  quality  might  be  appreciable. 

The  murmur  is  more  or  less  weakened  in  cases  of 
dilatation  of  the  air-cells,  or  vesicular  emphysema, 
the  sign,  in  these  cases,  being  often  accompanied  by 
changes  in  rhythm,  namely,  a  shortened  inspiration* 
and  a  prolonged  expiration.  Simple  weakness  of 
the  murmur  may  also  be  incident  to  partial  block- 
ing of  the  air-vesicles  with  blood  or  serum  in  cases 
of  pulmonary  extravasation  and  oedema.  A  defi- 
cient expansion  of  the  chest,  cither  on  one  side  or 
on  both  sides,  occasions  weakness  of  the  respiratory 
murmur.  Deficient  expansion  of  one  side,  or  of 
both  sides,  may  be  caused  by  paralysis,  bilateral, 
or  unilateral,  of  the  costal  muscles.  A  similar  effect 
is  caused  by  paralysis  of  the  diaphragm.  The  in- 
complete descent  of  the  diaphragm  from  pain,  as  in. 
peritonitis,  or  from  mechanical  obstacles,  as  in  peri- 
toneal dropsy,  pregnancy,  and  abdominal  tumors, 
weakens  the  respiratory  murmur,  the  increased  ac- 
tion of  the  costal  musclea  net  being  fully  compensa- 
tory. Unilateral  deficiency  of  expansion  of  the 
<'hest  is  caused  by  pain  in  intercostal  neuralgia, 
pleurodynia,  acute  pleurisy,  and  pneumonia;  it  is 
also  caused  by  the  presence  of  a  stratum  of  liquid, 


102  AUSCULTATION    IN     DISEASE. 

air,  or  a  thick  layer  of  lymph  between  the  lung  and 
the  chest-wall  in  pleurisy,  hydrothorax,  and  pneu- 
mothorax. Swelling  of  the  bronchial  mucous  mem- 
brane in  bronchitis  affecting  the  larger  tubes,  must 
diminish  somewhat  the  intensity  of  the  murmur. 
In  primary  bronchitis  the  murmur  is  diminished  on 
both  sides.  In  bronchitis  affecting  the  smaller  tubes 
the  murmur  is  greatly  diminished,  if  not  suppressed, 
on  both  sides.  Incomplete  obstruction  of  bronchial 
tubes  from  the  presence  of  mucus,  serum,  blood,  or 
pus,  has  this  effect  over  an  area  corresponding  to 
the  size  of  the  tubes  obstructed.  Spasm  of  the 
bronchial  muscular  fibres  in  paroxysms  of  asthma, 
diminishes,  if  it  do  not  suppress,  murmur  on  both 
sides.  Another  cause  of  diminution,  unilateral,  or 
within  a  limited  space  on  one  side,  is  the  pressure 
of  a  tumor  pressing  on  bronchial  tubes,  as  in  cases 
of  aneurism.  A  permanent  contraction  or  stricture 
of  bronchial  tubes  is  another  cause.  Not  infre- 
quently the  pressure  of  an  aneurismal  tumor  or  an 
enlarged  bronchial  gland  on  a  primary  bronchus, 
occasions  notable  weakness  of  the  murmur  over  the 
whole  of  one  side;  and  the  pressure  of  a  tumor  on 
the  trachea  weakens  the  murmur,  more  or  less,  on 
both  sides.  A  foreign  body  in  one  of  the  primary 
bronchi  weakens  it  on  one  side.  Diminution  of  the 
calibre  of  the  trachea  or  larynx  from  morbid  growths, 
the  presence  of  foreign  bodies,  fibrinous  exudations, 
accumulations  of  mucus,  submucous  infiltration, 
spasms  of  the  laryngeal  muscles,  and  swelling  of  the 
mucous  membrane,  weakens,  in  proportion  to  the 
amount  of  obstruction,  the  murmur  on  both  sides 
without  any  material  change  in  its  quality  and  pitch. 


MODIFICATIONS    OF    NORMAL    SOUNDS.      103 

Weakened  murmur  at  the  summit  of  the  chest, 
without  other  appreciable  abnormal  characters, 
occurs  in  some  cases  of  phthisis,  due  to  obstructed 
bronchial  tubes  from  coexisting  circumscribed  bron- 
chitis, or  to  deficient  superior  costal  movements  of 
the  chest,  as  well  as  to  the  presence  of  exudation  in 
the  air-vesicles. 

Diminished  intensity  of  the  vesicular  murmur  is 
thus  seen  to  be  a  respiratory  sign  entering  into  the 
diagnosis  of  a  considerable  number  of  diseases, 
namely,  emphysema,  paralysis  affecting  the  respira- 
tory muscles,  asthma,  abdominal  affections  interfer- 
ing with  the  diaphragmatic  movements,  intercostal 
neuralgia,  pneumonia,  hydrothorax,  bronchitis, 
aneurismal  and  other  tumors,  permanent  constric- 
tion or  stricture  of  bronchial  tubes,  laryngitis, 
cedema  of  the  glottis,  spasm  of  the  glottis,  the  vari- 
ous lesions  which  occasion  obstruction  of  the  larynx 
or  trachea,  and  phthisis. 

In  determining  a  slight  abnormal  weakness  of  the 
respiratory  murmur  at  the  summit  of  the  chest  on 
the  right  side,  the  normal  disparity  between  the  two 
sides  in  this  situation  is  to  be  borne  in  mind.  The 
vesicular  murmur  is  normally  less  intense  on  the 
right  than  on  the  left  side 

This  sign  occurring  in  so  many  diseases,  it  is  ob- 
vious that,  taken  alone,  that  is,  Independent  of  other 
signs,  it  has  not  any  special  diagnostic  significance. 
li  is.  however,  often  of  value  in  diagnosis,  when 
taken  in  connection  with  other  signs.  It  is  chiefly 
useful  when  it  exist-  either  over  the  whole  or  in  a 
part  of  the  chest  on  one  Bide. 

tinji/ircssid  Respiratory  Sound. — This  sign  is  easily 
defined,  namely,  absence  of  all  respiratory  Bound,  as 


104  AUSCULTATION    IN    DISEASE. 

the  name  signifies.     It  cannot,  of  course,  have  any 
characters  relating  to  intensity,  pitch,  and  quality. 

Suppression  of  respiratory  sound  represents  the 
same  physical  conditions  as  diminished  vesicular 
murmur;  the  physical  conditions  represented  by 
the  latter  sign,  existing  in  a  greater  degree,  occa- 
sion absence  of  all  sound.  It  suffices,  therefore,  to 
recapitulate  the  various  conditions  and  diseases  in 
connection  with  which  the  murmur  may  either  be 
diminished  or  suppressed.  Suppression  over  por- 
tions of  the  chest  may  be  due  to  dilatation  of  the 
air-cells  in  cases  of  emphysema.  It  occurs  from  the 
exclusion  of  air  from  the  vesicles  by  the  presence  of 
blood  and  serum  in  cases  of  pulmonary  extravasa- 
tion and  oedema.  Respiratory  sound  is  sometimes 
wanting  over  lung  solidified  in  cases  of  pneumonia 
and  phthisis.  Paralysis  of  the  muscles  concerned 
in  respiration  may  possibly  involve  feebleness  of  the 
respiratory  acts  sufficiently  to  render  the  murmur 
inappreciable.  In  intercostal  neuralgia,  pleuro- 
dynia, acute  pleurisy,  and  pneumonia,  the  move- 
ments of  the  affected  side  may  be  so  much  restricted 
as  to  abolish  the  murmur.  In  pleurisy  with  much 
effusion,  empyema,  hydrothorax,  pneumothorax,  the 
murmur  is  suppressed  over  either  a  part  or  the  whole 
of  the  affected  side,  the  extent  of  the  suppression 
corresponding  to  the  quantity  of  serum,  pus,  or  air 
within  the  pleural  cavity.  Swelling  of  the  mucous 
membrane  in  cases  of  bronchitis  affecting  the  larger 
bronchial  tubes  is  never  sufficient  to  suppress  the 
murmur,  but  plugging  of  more  or  less  of  the  tubes 
with  mucus  or  other  morbid  products  may  have  this 
effect.     In  cases  of  bronchitis,  the  murmur  is  some- 


MODIFICATIONS    OF    NORMAL    SOUNDS.      105 

times  fou ml  to  have  disappeared  over  a  certain  area, 
and  to  return  after  an  act  of  expectoration.  In 
bronchitis  affecting  the  smaller  tubes,  suppression 
of  the  murmur  is  not  infrequent.  It  occurs  from 
spasm  of  the  bronchial  muscular  fibres  in  cases  of 
asthma.  The  pressure  of  a  tumor,  morbid  growths, 
or  deposits  from  bronchi  within  the  lungs,  may 
abolish  respiratory  sound  over  a  portion  of  the 
chest,  and  permanent  stricture  or  obliteration  of 
bronchial  tubes  may  have  this  effect.  Respiratory 
sound  may  be  suppressed  over  the  whole  of  one 
side  from  the  pressure  of  an  aneurismal  or  some 
other  tumor  upon  one  of  the  primary  bronchi.  If 
the  tumor  press  upon  the  trachea,  the  obstruction 
may  be  sufficient  to  suppress  the  murmur  on  both 
sides.  A  foreign  body  lodged  in  a  primary  bron- 
chus may  suppress  the  murmur  on  one  side,  and, 
lodged  in  the  larynx  or  trachea,  the  murmur  may 
be  suppressed  on  both  sides.  The  different  affec- 
tions of  the  larynx  and  trachea  which,  in  proportion 
to  the  amount  of  obstruction,  weaken  the  murmur, 
may  render  it  inappreciable. 

Bronchial  or  Tubular  Respiration. — The  analogue  of 
this  sign  is  the  normal  laryngeal  or  tracheal  respi- 
ration (vide  page  82).  The  characters  which  dis- 
tinguish the  latter  normal  sign  from  the  normal 
vesicular  murmur,  are  those  which  arc  distinctive 
of  the  bronchial  or  tubular  respiration.  These  char- 
acters, relating  to  the  inspiratory  and  the  expiratory 
-omuls,  are  as  follows:  The  inspiratory  sound  is  of 
variable  intensity,  [ntensity  does  not  enter  into  the 
distinctive  characters  of  this  sign;  the  sound  may 

be    cither    louder    Or    weaker    than     the    inspiratory 


106  AUSCULTATION    IN    DISEASE. 

sound  in  health.  The  pitch  of  the  inspiratory 
sound  is  high.  The  quality  is  expressed  by  the 
term  tubular;  it  is  like  the  sound  produced  by 
blowing  through  a  tube,  this  quality  taking  the 
place  of  that  expressed  b}T  the  term  vesicular  in  the 
normal  respiration.  The  expiratory  sound  is  pro- 
longed ;  it  is  as  long  as,  or  longer  than,  the  sound 
of  expiration,  and  is  usually  louder.  The  pitch  is 
still  higher  than  that  of  the  inspiratory  sound.  The 
quality,  like  that  of  the  inspiratory  sound,  is  tubular, 
this  quality  taking  the  place  of  the  simple  blowing 
quality  of  the  expiratory  sound  in  the  normal  vesic- 
ular murmur.  With  the  normal  rhythm  of  the 
respiratory  acts  there  is  a  very  brief  interval  be- 
tween the  sounds  of  inspiration  and  expiration,  due 
to  the  fact  that  the  inspiratory  sound  ends  a  little 
before  the  end  of  the  inspiratory  act. 

The  morbid  physical  condition  represented  by 
this  important  sign  is  either  complete  or  consider- 
able solidification  of  lung.  Whenever  the  chest  is 
auscultated  over  lung  solidified,  if  there  be  not 
absence  of  respiratory  sound,  the  sound  is  tubular. 
This  significance  renders  the  sign  of  diagnostic  value 
in  the  diseases  which  involve  solidification.  The 
sign  per  se  denotes  simply  this  morbid  physical  con- 
dition ;  the  particular  disease  which  exists  is  ascer- 
tained b}^  means  of  the  associated  signs  and  the 
symptoms. 

Solidification  of  lung  is  incident  to  several  dif- 
ferent diseases.  In  lobar  pneumonia  it  is  due  to 
a  fibrinous  exudation  within  the  air-vesicles.  In 
phthisis  it  is  caused  by  an  exudation  in  the  same 
situation.    In  chronic  or  fibroid  pneumonia  the  lung 


MODIFICATIONS    OF    NORMAL    SOUNDS.      107 

is  solidified  by  an  interstitial  growth.  The  com- 
pression of  lung  from  either  pleuritic  effusion,  an 
accumulation  of  air  in  the  pleural  cavity,  or  the 
pressure  of  a  tumor,  causes  solidification  by  conden- 
sation. Collapse  of  pulmonary  lobules  also  solidifies 
by  condensation.  Coagulation  of  blood  within  the 
air-vesicles  (hemorrhagic  infarctus),  and  cancerous 
infiltration  or  growth,  are  other  causes  of  solidifica- 
tion. In  these  different  affections,  if  the  solidification 
be  complete  or  considerable,  this  sign  is  usually 
present;  it  is  always  present  if  there  be  not  suppres- 
sion of  respiratory  sound. 

It  is  sometimes  the  case  that  either  the  inspiratory 
or  the  expiratory  sound  is  wanting.  The  characters 
of  the  sign  suffice  for  its  recognition  if  either  the  in- 
spiratory or  the  expiratory  sound  be  alone  present; 
the  pitch  and  the  quality  are  distinctive.  Both 
sounds  are  often  so  intense  that  they  arc  diffused 
more  or  less  without  the  limits  of  the  solidified  por- 
tion of  lung.  The  expiratory  sound,  being  more 
intense  than  the  inspiratory,  is  transmitted  further 
than  the  latter.  This  explains  the  conjunction  some- 
times of  a  vesicular  inspiration  with  a  tubular  expi- 
ration :  and  a  cavernous  inspiration  may  he  conjoined 
with  a  tubular  expiration,  showing  the  proximity  of 
solidified  lung  in  the  former  case  to  healthy  lung, 
and.  in  the  latter  case,  to  a  pulmonary  cavity. 

The  sound  may  Beem  near  the  ear  or  to  come  from 
a  certain  distance.  The  latter  is  appreciable  in  some 
a  of  large  pleuritic  effusion;  the  tubular  respira- 
tion is  more  or  less  distant,  and  it  is  sometimes  dif- 
fused Over  the  whole  of  thi'  side  which  is  tilled  with 
liquid. 


108  AUSCULTATION    IN    DISEASE. 

Broncho-vesicular  Respiration. — This  name  was  in- 
troduced by  me,  in  1856,  to  denote  the  combination, 
in  varying  proportions,  of  the  characters  of  the 
bronchial  or  tubular,  and  of  the  normal  vesicular 
respiration.  The  name  expresses  such  a  combina- 
tion. It  embraces  modifications  to  which  have  been 
applied  the  terms,  rude,  rough,  and  harsh  respiration, 
and  those  included  by  German  authors  under  the 
name  indeterminate  respiratory  sounds. 

The  sign  represents  the  different  degrees  of  solidi- 
fication of  lung,  between  an  amount  so  slight  as  to 
occasion  only  the  smallest  appreciable  modification 
of  the  respirator}7  sound,  and  an  amount  so  great  as 
to  approxinate  closely  to  the  degree  giving  rise  to 
bronchial  or  tubular  respiration.  In  other  words, 
all  the  gradations  of  respiratory  modifications,  caused 
by  incomplete  or  an  inconsiderable  solidification, 
which  fall  short  of  bronchial  or  tubular  respiration, 
are  embraced  under  the  name  broncho-vesicular. 
The  gradations  correspond  to  the  amount  of  solidi- 
fication, that  is,  they  show  the  solidification  to  be 
either  very  slight,  slight,  moderate,  or  nearly  suffi- 
cient to  be  considered  as  considerable  or  complete. 
The  sign  is,  therefore,  important  as  evidence,  first, 
of  the  existence  of  solidification;  and,  second,  of  the 
degree  of  solidification. 

Analyzing  this  sign,  the  most  distinctive  feature 
is  the  combination  of  the  vesicular  and  the  tubular 
quality  in  the  inspiratory  sound.  These  two  quali- 
ties may  be  combined  in  variable  proportions.  The 
pitch  of  the  sound  is  raised  in  proportion  as  the 
tubular  predominates  over  the  vesicular  quality. 
The  expiratory  sound  is  more  or  less  prolonged, 


MODIFICATIONS    OF    NORMAL  SOUNDS.      109 

tubular  in  quality,  and  the  pitch  is  raised.  The  pro- 
longation of  this  sound,  its  tubular  quality,  and  the 
highness  of  pitch,  are  proportionate  to  the  predom- 
inance of  the  tubular  over  the  vesicular  quality  in 
the  inspiratory  sound.  If  the  solidification  of  lung 
be  slight,  the  characters  of  the  normal  vesicular 
respiration  predominate ;  that  is,  the  inspiratory 
sound  has  but  a  small  proportion  of.  the  tubular 
quality,  and  is  but  little  raised  in  pitch,  the  expira- 
tory sound  being  not  much  prolonged,  its  tubularity 
not  marked,  the  pitch  not  high.  If,  on  the  other 
hand,  the  solidification  of  lung  be  almost  enough  to 
give  a  bronchial  respiration,  the  inspiratory  sound 
has  only  a  little  vesicular  quality,  the  tubular  quality 
predominating,  the  pitch  proportionately  raised;  and 
the  expiratory  sound  is  prolonged,  tubular,  and  high, 
nearly  to  the  same  extent  as  in  the  bronchial  respi- 
ration. The  less  the  solidification  the  more  the 
characters  of  the  normal  vesicular  predominate  over 
those  of  the  bronchial  respiration,  and,  per  contra, 
the  greater  the  solidification  the  more  the  characters 
of  the  bronchial  predominate  over  those  of  the  nor- 
mal vesicular  respiration.  Daily  auscultation  in  a 
case  of  lobar  pneumonia  during  the  stage  of  resolu- 
tion affords  an  opportunity  to  study  all  the  grada- 
tions of  this  sign.  After  resolution  has  made  BOme 
progress  the  inspiratory  sound  is  no  longer  purely 
tubular,  but  the  ear  appreciates  a  little  admixture 
of  the  vesicular  quality  and  the  pitch  is  Blightly 
lowered.  As  resolution  goes  on  the  vesicular  quality 
increases, the  pitch  is  correspondingly  Lowered,  until, 
at  length,  no  tubularity  remains,  and  the  pitch  be- 
comes normal.     Meanwhile,  as  the  vesicular  quality 

10 


110  AUSCULTATION    IN    DISEASE. 

increases  in  the  inspiratory  sound,  the  expiratory 
sound  is  less  and  less  prolonged,  high  and  tubular, 
until  it  becomes,  as  in  health,  short,  low,  and 
blowing. 

The  broncho-vesicular  respiration  is  an  important 
diagnostic  sign  in  all  the  affections  which  involve 
partial  solidification  of  lung.  In  lobar  pneumonia, 
as  just  stated,  it  denotes  the  progress  made  from  day 
to  day  in  resolution.  It  is  found  also  in  an  earlier 
stage,  before  the  solidification  is  sufficient  to  give 
rise  to  a  purely  bronchial  respiration.  It  is  a  valu- 
able sign  in  phthisis,  affording  evidence,  not  only  of 
the  fact  of  solidification,  but  of  its  degree  and  extent. 
The  signs  enter  into  the  diagnosis  of  interstitial 
pneumonia,  hemorrhagic  infarctus,  condensation  of 
lung  from  the  pressure  of  either  liquid,  air,  or  a 
tumor,  and  from  collapse  of  pulmonary  lobules.  It 
may  be  stated  with  respect  to  this  sign,  that  it  is 
always  present  if  the  lung  be  partially  solidified,  pro- 
vided there  be  not  either  suppression  of  respiratory 
sound,  or  such  a  degree  of  feebleness  that  the  dis- 
tinctive characters  are  undeterminable.  As  with  the 
bronchial  respiration,  so  with  the  broncho-vesicular, 
either  the  inspiratory  or  the  expiratory  sound  may 
be  wanting.  The  characters  of  the  sign  are  then  to 
be  determined  as  they  are  manifested  in  the  sound 
which  is  present,  namely,  the  combination  of  the 
vesicular  and  the  tubular  quality,  with  more  or  less 
elevation  of  pitch,  if  only  an  inspiratory  sound  may 
be  heard,  and  the  amount  of  prolongation,  tubu- 
larity, and  elevation  of  pitch,  if  there  be  only  an 
expiratory  sound. 

In  determining  the  presence  of  this  morbid  sign 


MODIFICATIONS    OF    NORMAL  SOUNDS.      Ill 

at  the  summit  of  the  chest  on  the  right  side,  it  is  to 
be  borne  in  mind  that  the  respiratory  murmur  on 
this  side  has,  in  health,  as  compared  with  the  respi- 
ratory murmur  at  the  summit  on  the  left  side,  more 
or  less  of  the  characters  of  the  broncho-vesicular 
respiration  (vide  Normal  Broncho-vesicular  Respira- 
tion, page  108). 

Cavernous  Respiration. — The  modifications  which 
constitute  the  distinctive  characters  of  this  sign,  are 
produced  by  the  entrance  of  air  into  a  cavity  with 
the  act  of  inspiration,  and  its  exit  from  the  cavity 
with  the  act  of  expiration.  This  passage  of  air  into 
and  from  a  cavity  can  only  take  place  where  the 
walls  of  the  cavity  collapse  more  or  less  in  expira- 
tion and  expand  in  inspiration.  Pulmonary  cavities 
occur  chiefly  in  cases  of  phthisis.  They  occur,  but 
with  comparative  infrequency,  as  a  result  of  circum- 
scribed abscess  and  gangrene  of  lung. 

A  well-marked  cavernous  respiration  has  char- 
acters which  arc  hiffhlv  distinctive  when  this  sign  is 
contrasted,  on  the  one  hand,  with  either  the  bron- 
chial or  broncho-vesicular  respiration,  and,  on  the 
other  hand,  with  the  normal  vesicular  murmur. 
These  distinctive  characters  relate  both  to  the  inspi- 
ratory and  expiratory  sound.  The  inspiratory  sound 
i-  neither  vesicular  nor  tubular  in  quality,  and  the 
pitch  is  low  as  compared  with  the  bronchial  respira- 
tion. As  regards  quality,  we  may  say  of  it,  as  of 
the  expiratory  sound  in  the  normal  vesicular  respi- 
ration, it  is  simply  a  blowing  sound.  The  expira- 
tory sound  has  the  same  quality  as  the  inspiratory, 
and  it  is  lower  in  pitch.  Its  duration  is  variable. 
The  intensity  <>t'  both  the   inspiratory  and    the   expi- 


112  AUSCULTATION"    IN    DISEASE. 

ratory  sound  varies ;  intensity  does  not  enter  into 
the  distinctive  characters  of  this  sign  more  than  into 
those  of  the  bronchial  and  the  broncho-vesicular 
respiration.  These  distinctive  characters  of  the 
cavernous  respiration,  as  regards  pitch  and  quality, 
especially  of  the  expiratory  sound,  were  first  pointed 
out  by  me  in  1852.1  Prior  to  this  date  the  bronchial 
and  the  cavernous  respiration  were  considered  as 
having  identical  characters,  or,  at  all  events,  as  not 
distinguishable  from  each  other.  Following  Skoda, 
these  two  signs  are  still  considered  as  essentially 
identical  by  German  authors.  With  a  practical 
knowledge  of  the  foregoing  characters  distinctive  of 
the  cavernous  respiration,  there  is  no  difficulty  in 
discriminating  this  sign  from  the  bronchial  respira- 
tion. The  sign  is  more  likely  to  be  confounded 
with  the  normal  vesicular  murmur,  inasmuch  as  it 
differs  from  the  latter  only  in  the  absence  in  the  in- 
spiratory sound  of  the  vesicular  quality.  Against 
this  error  the  student  is  to  be  cautioned.  It  is  most 
likely  to  be  made  when  the  inspiratory  sound  is 
much  weakened,  and,  consequently,  the  vesicular 
quality  less  distinctly  appreciable  than  when  the 
sound  is  more  or  less  intense. 

A  cavernous  respiration  is  limited  to  a  space  more 
or  less  circumscribed,  the  area  corresponding  to  the 
site  and  the  size  of  the  cavity.  Occurring,  for  the 
most  part,  in  cases  of  phthisis,  it  is  much  oftener 
found  at  the  summit  than  elsewhere  over  the  chest. 
It  is  not  constantly  found  where  there  is  a  cavity  with 

1  Prize  Essay  on  Variations  of  Pitch  in  the  Sounds  obtained  by 
Percussion  and  Auscultation.  Transactions  of  the  American 
Medical  Association,  1852. 


MODIFICATIONS    OF    NORMAL    SOUNDS.      113 

flaccid  walls.  It  may  be  temporarily  suppressed  by 
the  presence  of  liquid  within  the  cavity,  and  by  ob- 
struction of  the  orifices  communicating  with  bron- 
chial  tubes,  or  of  the  latter.  It  may  be  wanting  at 
one  moment,  and  an  act  of  expectoration  may  cause 
it  to  reappear.  Hence  absence  of  cavity  cannot  be 
predicated  on  the  absence  of  the  sign  at  a  single  ex- 
amination. Moreover,  if  a  cavity  be  not  situated 
near  the  pulmonary  superficies,  and  solidified  lung 
intervene  between  it  and  the  walls  of  the  chest,  the 
cavernous  sign  may  be  drowned  in  a  loud  bronchial 
respiration.  For  this  reason,  while  the  cavernous 
sign  is  positive  evidence  of  a  cavity,  the  absence  of 
the  sign  is  not  proof  that  a  cavity  does  not  exist. 

In  some  cases  of  perforation  of  lung  with  pneumo- 
thorax, the  passage  of  air  to  and  fro  through  the  per- 
foration may  give  rise  to  the  cavernous  respiration. 
As  a  rule,  however,  under  these  circumstances,  an- 
other sign  is  produced,  namely,  the  amphoric  respi- 
ration. 

The  cavernous  respiration  may  be  reproduced  by 
the  inflation  of  lungs  after  their  removal  from  the 
body,  the  binaural  stethoscope  being  placed  over  a 
cavity.  This  is  true,  also,  of  the  bronchial  and  the 
broncho-vesicular  respiration.  These  signs  may  be 
thus  illustrated  not  infrequently  after  death  from 
phthisis,  in  lungs  in  which  are  cavities  together  with 
portions  completely  or  moderately  Bolidified. 

The  distinctive  characters  of  the  cavernous  respi- 
ration may  also  be  illustrated  by  means  of  a  small 
[ndia-rubber  balloon  with  an  opening  at  opposite 
ends.  Inflating  the  balloon  through  a  tube  intro- 
duced into  one  opening  produces  a  sound  analogous 

10* 


114  AUSCULTATION    IN    DISEASE. 

to  the  cavernous  inspiration,  and  the  expulsion  of 
the  air  by  the  elasticity  of  the  balloon  produces  a 
sound  analogous  to  the  cavernous  expiration.  A 
Davidson's  syringe  may  be  used  to  inflate  the 
balloon.  The  sounds  are  heard  by  applying  lightly 
to  the  balloon  the  binaural  stethoscope.  This  illus- 
tration demonstrates  the  mechanism  of  the  cavern- 
ous respiration. 

Broncho-cavernous  Respiration. — In  this  sign,  as  the 
name  denotes,  the  characters  of  the  bronchial  and 
the  cavernous  respiration  are  combined.  These 
characters  may  be  combined  in  different  ways,  as 
well  as  in  variable  proportions.  If  a  cavity  be  situ- 
ated in  proximity  to  solidified  lung,  the  quality  and 
pitch  of  the  inspiratory  and  the  expiratory  sound 
may  show  an  admixture  of  the  characters  of  the  two 
signs,  and  to  a  practised  ear  the  combination  is  dis- 
tinctly recognizable.  This  is  one  of  the  forms  of 
broncho-cavernous  respiration ;  the  sounds  are  not 
sufficiently  high  and  tubular  for  bronchial,  nor  suffi- 
ciently low  and  blowing  for  cavernous  respiration. 
Another  form  consists  of  an  inspiratory  sound,  the 
first  part  of  which  is  tubular,  and  the  latter  part 
cavernous.  Examples  of  this  form  are  not  ex- 
tremely infrequent.  This  form  has  been  recently 
described  by  Seitz  under  the  name,  "  metamorphosing 
respiration"  Still  another  form  is  a  cavernous  in- 
spiratory, with  a  bronchial  or  tubular  expiratory 
sound.  In  the  latter  form,  the  bronchial  expiration 
proceeds  from  solidified  lung  situated  near  the  cavity, 
the  intensity  of  the  sound  being  sufficient  to  drown 
the  cavernous  expiration. 

When,  as  often  happens,  a  cavity  is  situated  in 


MODIFICATIONS    OF    NORMAL    SOUNDS.       115 

close  proximity  to,  or,  it  may  be,  surrounded  by 
solidified  lung,  the  cavernous  and  the  bronchial 
respiration  are,  as  it  were,  in  juxtaposition,  and 
such  instances  offer  an  excellent  opportunity  to 
study  the  points  distinguishing  these  signs  from 
each  other;  and,  generally,  at  a  short  distance  the 
normal  vesicular  murmur  may  be  found,  so  that 
both  morbid  signs  may  be  compared  with  the  latter. 
Within  a  circumscribed  area  sometimes  are  exem- 
plified the  characters  of  the  normal  murmur,  and  of 
the  two  morbid  signs  just  mentioned,  together  with 
those  of  the  broncho-vesicular  respiration. 

Vesiculo-carernous  Respiration. — It  is  sometimes  evi- 
dent that  the  vesicular  and  the  cavernous  quality  are 
combined  in  the  inspiratory  sound.  This  occurs 
when  a  cavity  is  surrounded,  not  by  solidified,  but 
by  healthy  lung.  Under  these  circumstances,  over 
the  site  of  the  cavity  the  inspiratory  sound  may  be 
as  loud  as,  or  louder  than,  that  around  the  cavit}T, 
but  the  quality  is  not  purely  cavernous;  some  vesic- 
ular quality  is  appreciable.  A  vesiculocavernous 
respiration,  then,  is  a  cavernous  respiration  plus 
some  vesicular  quality  derived  from  the  air-vesicles 
which  are  proximate  to  the  cavity.  This  sign  is 
corroborated  by  other  associated  Bigns  .showing  the 
existence  of  a  cavity  and  its  localization. 

Amphoric  Respiration. — The  term  amphoric  has  a 
significance  when  applied  to  auscultatory  sounds, 
analogous  to  that  which  it  has  in  percussion  ;  it  de- 
notes a  musical  intonation  which  may  be  compared 
to  the  sound  produced  by  blowing  upon  the  open 
mouth  of  a  decanter  or  phial.  Whenever  the  re- 
spiratory sound   has    this    intonation,   it   denotes  a 


116  AUSCULTATION    IN    DISEASE. 

space  containing  air  which  is  not  expelled  with  the 
act  of  expiration.  Air  in  the  pleural  cavity,  with 
perforation  of  lung,  is  the  physical  condition  most 
frequently  represented  by  this  sign.  It  is  a  valu- 
able diagnostic  sign  in  cases  of  pneumothorax ;  but 
it  is  not  always  present  in  that  affection,  certain  ac- 
cessory conditions  being  requisite,  namely,  perfora- 
tion above  the  level  of  liquid,  and  an  unobstructed 
communication  of  the  bronchial  tubes,  through  the 
opening,  with  the  pleural  space  containing  air. 
While,  therefore,  its  presence  is  significant  of 
pneumothorax,  its  absence  is  by  no  means  sufficient 
to  exclude  this  affection.  Not  infrequently  it  is  a 
sign  of  a  phthisical  cavity  with  rigid  walls  which  do 
not  collapse  with  the  act  of  expiration.  The  same 
contingencies  affect  its  production  here  as  in  cases 
of  pneumothorax.  Whenever  amphoric  respiration 
is  present,  if  pneumothorax  be  excluded  by  the  ab- 
sence of  the  other  signs  which  are  diagnostic  of  this 
affection,  the  sign  is  proof  of  the  existence  of  a  pul- 
monary cavity,  the  walls  of  which  are  not  flaccid. 
The  sign  then  takes  the  place  of  the  ordinary  cav- 
ernous respiration  which  has  been  described. 

The  amphoric  sound  may  accompany  either  respi- 
ration or  expiration,  or  both.  Amphoric  respiration 
may  be  artificially  illustrated  by  connecting  an  Xndia- 
rubber  bag  of  considerable  size  (such  as  is  contained 
within  a  foot-ball)  with  a  flexible  tube,  and  after 
dilating  it  with  air,  inflating  it  forcibly  either  by  a 
pair  of  bellows  or  by  the  mouth,  holding  the  bag 
close  to  the  ear.  The  amphoric  sound  thus  pro- 
duced represents  the  amphoric  respiration  as  a 
sign  in  pneumothorax.     As  the  sign  of  a  tubercu- 


MODIFICATIONS    OF    NORMAL    SOUNDS.      117 

lous  cavity  it  may  be  illustrated  by  a  similar  experi- 
ment, using  an  India-rubber  bag  of  the  size  of  an 
egg  or  orange.  I  have  localized  a  tuberculous 
cavity  with  rigid  walls  in  the  centre  of  a  lobe,  by 
inflating  artificially  phthisical  lungs  after  their  re- 
moval from  the  body. 

Shortened  Inspiration. — The  inspiratory  sound  is 
somewhat  shortened  in  bronchial  or  tubular  respira- 
tion. This  modification  enters  into  the  characters 
of  that  sign,  the  quality  of  the  sound  being  tubular, 
and  the  pitch  high.  The  shortening  is  due  to  the 
sound  ending  before  the  inspiratory  act  ends;  the 
sound  is  said  to  be  unfinished.  Shortening  of  the 
sound  occurs,  however,  when  it  is  not  an  element 
in  the  bronchial  respiration.  The  shortening  is 
then  due  to  the  sound  not  beginning  with  the  in- 
spiratory act;  this  is  distinguished  as  deferred  in- 
spiratory sound.  A  deferred  inspiratory  sound  not 
tubular  in  quality,  but  more  or  less  vesicular,  and 
not  notably  raised  in  pitch,  is  a  sign  of  pulmonary 
or  vesicular  emphysema.  It  is  a  sign  of  value  in 
connection  with  the  diagnosis  of  that  disease. 

The  student  should  note  the  distinctions  just 
stated  which  relate  to  pitch  and  quality.  Suppose 
an  inspiratory  sound  to  be  present  without  an  ex- 
piratory sound;  if  the  sound  be  shortened  at  the 
end  of  the  inspiration,  the  pitch  high,  and  the 
quality  tubular,  it  is  bronchial  respiration,  denoting 
complete  or  considerable  solidification  of  lung,  but 
if  the  shortening  be  at  the  beginning  <>t  respiration, 
the  pitch  comparatively  low,  and  vesicular  quality 
be  appreciable,  the  sign  denotes  emphysema.  The 
differential   points  thus  arc,  the  inspiratory  sound 


118  AUSCULTATION    IN    DISEASE. 

either  unfinished  or  deferred,  the  pitch  either  high 
or  low,  and  the  quality  either  tubular  or  vesicular. 
Attention  to  these  points  is  essential  in  order  to 
avoid  error  in  the  interpretation  of  the  sign. 

Prolonged  Expiration. — The  length  of  the  expira- 
tory sound  in  health  varies  in  different  persons. 
The  sound  is  sometimes  considerably  prolonged ;  it 
may  be  nearly  as  long  as  the  sound  of  inspiration. 
There  is  no  difficulty  in  recognizing  this  as  a  normal 
peculiarity,  from  the  fact  that  the  murmur  has  the 
pitch  and  quality  of  health.  An  unusual  length  of 
the  expiratory  sound,  within  the  range  of  health,  is 
usually  observed  at  the  summit  of  the  chest,  and 
especially  on  the  right  side.  It  is  important  to  bear 
in  mind  that  at  the  summit  of  the  chest  on  the  right 
side,  and  sometimes  also  on  the  left  side,  a  prolonged 
expiratory  sound,  more  or  less  raised  in  pitch,  and 
tubular  in  quality,  may  be  a  normal  peculiarity.  It 
follows  that  a  prolonged,  and  even  a  high  and  tu- 
bular expiration  at  the  summit  of  the  chest,  must 
not  be  reckoned  as  a  morbid  sign  unless  it  be  asso- 
ciated with  other  signs  denoting  disease.  The  laws 
of  the  disparity  between  the  two  sides  of  the  chest 
at  the  summit  are  to  be  taken  into  account  {vide  p. 
87).  If  the  expiration  be  longer  on  the  left  than  on 
the  right  side,  it  is  abnormal ;  so,  also,  is  a  high- 
pitched  tubular  expiration  heard  on  the  left  and  not 
on  the  right  side. 

The  significance  of  an  abnormally  prolonged  ex- 
piration depends  on  its  pitch  and  quality.  If  it  be 
high  and  tubular,  it  denotes  solidification  of  lung. 
It  is,  in  fact,  bronchial  respiration.  As  already 
stated,  in  bronchial  or  tubular  respiration  the   in- 


MODIFICATIONS    OF    NORMAL   SOUNDS.      119 

spiratory  sound  is  sometimes  wanting,  and  the 
presence  of  the  sign  is  then  to  he  determined  by 
the  characters,  relating  to  pitch  and  quality,  of  the 
expiratory  sound.  The  same  statement  holds  true 
with  respect  to  broncho-vesicular  respiration  when 
this  approximates  to  the  bronchial.  At  the  summit 
of  the  chest,  the  characters  of  the  inspiratory  sound, 
and  associated  morbid  signs,  always  enable  the  aus- 
cultator  to  determine  whether  a  prolonged  high  and 
tubular  expiration  be,  or  be  not,  abnormal.  A  pro- 
longed expiration,  which  is  low  in  pitch  and  blowing 
in  quality,  that  is,  with  the  characters  of  health, 
aside  from  length,  may  belong  to  a  cavernous  expi- 
ration. This  is  to  be  determined  by  the  characters 
of  the  inspiration,  and  by  other  associated  signs. 
Exclusive  of  cavernous  respiration,  an  abnormally 
prolonged  expiratory  sound  of  low  pitch  and  non- 
tubular,  denotes  vesicular  emphysema.  It  is  asso- 
ciated then  with  a  weakened  and  deferred  inspiratory 
sound.  A  prolonged  expiratory  sound,  in  cases  of 
emphysema,  is  invariably  low  and  non-tubular.  If 
it  have  not  these  characters,  it  is  not  a  sign  of  em- 
physema, but  belongs  to  bronchial  or  broncho-vesic- 
ular respiration.  Attention  to  these  differential 
points  is  to  be  enjoined  upon  the  student. 

A  prolonged  expiration  at  the  summit  of  the  chest 
on  the  right  side  is  sometimes  incorrectly  considered 
to  be  evidence  of  phthisis.  It  is  to  be  recollected, 
in  the  first  place,  that  prolongation  of  this  sound 
with  a  normal  pitch  and  quality,  is  never  evidence 
of  solidification  of  lung  either  from  phthisis  or  any 
other  disease  :  and  in  the  second  place,  even  if  the 
pitch  be  high,  and   the  quality  tubular,  that  it  is  not 


120  AUSCULTATION    IN    DISEASE. 

to  be  regarded  as  abnormal  provided  the  inspiratory 
sound  is  unchanged  and  other  signs  of  disease  are 
not  present.  At  times  in  bronchitis  there  is  a  pro- 
longed expiratory  sound  which  may  be  distinguished 
as  a  sonorous  expiration,  not  amounting  to  a  rale. 
This  is  liable  to  be  mistaken  for  broncho-vesicular 
breathing. 

The  importance  of  observing  the  pitch  and  quality 
of  a  prolonged  expiration  was  pointed  out  in  my 
work  on  "Physical  Exploration,"  in  1850.  The 
difference  as  regards  the  significance  of  a  high  pitch 
with  a  tubular  quality  from  a  low  pitch  with  a 
simply  flowing  quality,  has  not,  as  yet,  received 
from  medical  writers  the  attention  which  it  claims. 

Interrupted  Respiration. — To  this  sign  have  been 
applied  other  names,  such  as  jerking,  wavy,  cogged 
wheel,  and  by  French  writers  the  names  entrecoupee 
and  saccadee.  The  modification  is  either  of  the  in- 
spiration or  of  the  expiration,  or  of  both.  The  in- 
spiratory, however,  much  more  frequently  than  the 
expiratory,  sound  is  interrupted.  The  sound,  instead 
of  being  continuous,  is  broken  into  one,  two,  or  more 
parts.  This  is  the  characteristic  of  the  sigu.  If  at 
the  same  time  there  be  alterations  in  pitch  and 
quality,  the  interruption  is  merely  incidental  to 
other  signs,  namely,  the  bronchial,  broncho-vesic- 
ular, or  cavernous  respiration.  To  constitute  it  a 
distinct  sign,  the  interruption  must  be  the  only  ap- 
preciable change.  As  a  distinct  sign  it  has  but  little 
diagnostic  value. 

Interrupted  respiration  is  sometimes  found  in 
healthy  persons.  It  is  confined  to  the  summit  of 
the  chest,  and  oftener  on  the  left  than  the  right  side. 


MODIFICATIONS    OF    NORMAL   SOUNDS.      121 

Existing  without  any  other  signs,  therefore,  it  is  not 
evidence  of  disease.  It  is  of  value  only  in  the  diag- 
nosis of  phthisis.  Associated  with  other  signs,  when 
the  latter  are  not  marked,  it  is  entitled  to  a  certain 
amount  of  weight  in  the  diagnosis. 

Interrupted  respiratory  sounds,  of  course,  occur 
when  there  is  interruption  in  the  respiratory  move- 
ments. This  happens  in  cases  of  pleurisy,  pleuro- 
dynia, or  intercostal  neuralgia.  Owing  to  the  pain 
caused  by  the  movements  in  respiration,  the  patient 
may  breathe,  not  continuously,  but  with  a  series  of 
jerking  movements.  Sometimes  interrupted  breath- 
ing is  observed  in  persons  who  are  excited  or  agitated 
when  auscultation  is  practised.  In  all  these  instances 
interruption  in  the  respiratory  sounds  is  found  over 
the  whole  chest,  whereas,  when  it  is  an  abnormal 
sign  in  cases  of  phthisis,  it  is  limited  to  the  summit 
on  one  side  of  the  chest,  and  there  is  no  interruption 
manifested  in  the  mode  of  breathing. 

Reviewing  the  foregoing  signs,  they  may  be  dis- 
tributed into  three  classes,  as  follows:  1st.  Signs, 
the  distinctive  characters  of  which  relate  to  either 
the  absence  or  the  intensity  of  sound.  This  class 
embraces,  (a)  increased  intensity  of  the  vesicular 
murmur;  (b)  diminished  intensity  of  the  vesicular 
murmur;  and  (c)  suppression  of  respiratory  sound. 
2d.  Signs,  the  distinctive  characters  of  which  relate 
especially  to  pitch  and  quality.  In  this  class  belong, 
(a)  bronchia]  or  tubular  respiration;  (b)  broncho- 
vesicular  respiration ;  (c)  cavernous  respiration;  (d) 
broncho-cavernous  respiration;  (e)  vesiculo-cavern- 
oue  respiration;  and  (f)  amphoric  respiration.     3d. 

ii 


122  AUSCULTATION    IN    DISEASE. 

Signs,  the  distinctive  characters  of  which  relate 
especially  to  rhythm,  namely,  (a)  shortened  inspira- 
tion;  (b)  prolonged  expiration;  and  (c)  interrupted 
inspiration. 

Adventitious  Respiratory  Sounds,  or  Rales. 

Adventitious  respiratory  sounds,  or,  adopting  the 
French  term,  rales,  are  distinguished  from  the 
morbid  signs  already  considered,  by  the  fact  that 
they  have  no  analogues  in  health  ;  in  other  words, 
they  are  not  normal  sounds  abnormally  modified, 
but  wholly  new  sounds.  A  convenient  classifica- 
tion of  these  signs  is  based  on  the  different  ana- 
tomical situations  in  which  they  are  produced. 
This  classification  is  as  follows :  1st.  Laryngeal  and 
tracheal  rales;  2d.  Bronchial  rales;  3d.  Vesicular 
rfdes;  4th.  Cavernous  rales;  5th.  Pleural  rales; 
and,  6th.  Indeterminate  rales.  Compared  with 
each  other,  as  regards  their  characters,  they  admit 
of  being  divided  into  dry  and  moist  rales,  the  latter 
being  evidently  due  to  the  presence  of  liquid. 

Laryngeal  and  Tracheal  Rales. — The  rales  produced 
within  the  larynx  and  trachea  may  be  either  moist 
or  dry.  The  moist  or  bubbling  sounds  are  pro- 
duced when  mucus  or  other  liquid  accumulates  in 
these  sections  of  the  air-tubes.  This  occurs  fre- 
quently in  the  moribund  state,  and  the  sounds  are 
then  known  as  the  "  death-rattles."  When  not  in- 
cident to  this  state,  they  denote  either  insensibility 
to  the  presence  of  liquid,  as  in  coma,  or  inability  to 
effect,  the  removal  of  the  liquid  by  acts  of  expectora- 
tion.    The  sounds  are  heard  at  a  distance.     They 


MOIST    BRONCHIAL    RALES.  123 

exemplify,  on  a  large  scale,  moist  or  bubbling  aus- 
cultatory sounds  which  are  produced  within  the 
bronchial  tubes.  Dry  sounds  produced  within  the 
larynx  or  trachea  are  caused  by  spasm  of  the  glottis, 
and  by  diminution  of  the  calibre,  either  at  or  below 
the  glottis,  from  oedema,  exudation,  the  presence  of 
a  foreign  body,  or  the  pressure  of  a  tumor.  The 
dry  sounds  are  distinguished  as  whistling,  wheezing, 
crowing,  whooping,  etc.  They  are  heard  at  a  dis- 
tance, and  they  also  exemplify  auscultatory  sounds 
representing  analogous  conditions  in  the  bronchial 
tubes.  Characteristic  sounds  produced  at  the  glottis 
by  spasm  enter  into  the  diagnosis  of  certain  affections, 
namely,  laryngismus  stridulus,  pertussis,  croup,  and 
aneurism  involving  excitation  of  the  recurrent  laryn- 
geal nerve.  Other  sounds  are  due  to  paralysis  of 
the  laryngeal  muscles.  Again,  dry  sounds  produced 
by  stenosis  of  the  trachea  from  the  pressure  of  an 
aneuri8mal  or  other  tumor,  cicatrization  of  ulcers, 
and  morbid  growths,  are  of  diagnostic  importance. 
Although  audible  without  auscultation,  these  dif- 
ferent sounds,  with  reference  to  the  precise  situation 
at  which  they  are  produced,  may  sometimes  be 
studied  with  advantage  by  means  of  the  stethoscope. 
They  are  embraced  under  the  name  stridor.  The 
respiration,  voice,  and  cough,  when  accompanied  by 
these  sounds,  are  said  to  be  stridulous. 

Moist  Bronchial  Rales. 

The  moist  bronchial  rales  arc  bubbling  sounds 
produced  in  different  branches  of  the  bronchial  tree. 
They  are  sounds  of  which  the  "tracheal  rattles"  arc 


124  AUSCULTATION    IN    DISEASE. 

an  exaggerated  type.  They  may  be  imitated  by 
blowing  into  liquids  through  tubes  differing  in  size. 
They  may  also  be  produced  in  the  lungs  of  the 
sheep  or  the  calf,  after  removal  from  the  body,  by 
injecting  into  the  bronchi  glycerin  or  some  other 
liquid,  and  imitating  the  respiratory  acts  by  means 
of  a  pair  of  bellows,  auscultation  being  practised 
with  the  stethoscope  applied  upon  the  surface  of  the 
lung,  or  with  several  thicknesses  of  cloth  intervening. 
The  bubbles  seem  to  be  large  or  small  according  to 
the  size  of  the  bronchial  tubes  in  which  they  are 
produced.  Apparent  differences  in  the  size  of  the 
bubbles  are  distinguished  by  the  names  coarse  and 
fine.  In  the  primary  and  secondary  bronchial 
branches  the  moist  sounds  are  relatively  quite 
coarse;  they  are  less  so  in  tubes  of  the  third  or 
fourth  dimensions;  in  smaller  tubes  they  become 
fine,  and  in  those  of  minute  size  they  become  ex- 
tremely fine.  Extremely  fine  bubbling  sounds  con- 
stitute what  has  been  known  as  the  subcrepitant 
rale,  so  called  because  it  approaches  in  character  to 
the  crepitant  rale  produced  within  the  air-vesicles 
and  bronchioles.  We  may  thus  judge  of  the  size  of 
the  bronchial  tubes  in  which  the  rales  are  produced 
by  their  comparative  coarseness  or  fineness.  Fre- 
quently, however,  coarse  and  fine  rales  are  inter- 
mingled, and  generally  those  which  are  either  coarse 
or  fine  are  not  uniform,  but  appear  to  be  of  unequal 
size.  In  all  the  varieties  of  the  moist  bronchial  rales, 
the  bubbling  character  of  the  sounds  is  sufficiently 
distinctive  for  their  recognition.  The  differentiation 
of  the  so-called  subcrepitant  from  the  crepitant  rale 
alone  involves  some  nice  points  of  distinction. 


MOIST    BRONCHIAL    RALES.  125 

Coarse  bubbling  rales  sometimes  occur  iti  acute 
bronchitis  affecting  the  larger  bronchial  tubes. 
Their  occurrence  is  exceptional,  because,  in  gen- 
eral, the  mucus  within  the  tubes  does  not  ac- 
cumulate sufficiently  and  is  too  consistent  for  the 
production  of  bubbling  sounds.  These  rales  occur 
in  cases  in  which  the  mucus  is  unusually  thin  and 
either  more  abundant  than  usual  or  an  accumulation 
takes  place  in  consequence  of  inability  to  expec- 
torate freely.  These  conditions  are  wanting  in  the 
majority  of  the  cases  of  ordinary  acute  bronchitis. 
A  muco-purulent  liquid  in  cases  of  chronic  bron- 
chitis is  better  suited  for  the  production  of  bubbling 
sounds  than  simple  mucus.  Moreover,  coarse  rales 
are  heard  oftener  in  children  than  in  adults,  because 
the  former  do  not  voluntarily  expectorate  as  freely 
as  the  latter.  Serous  transudation  (bronchorrhoea) 
into  tubes  of  large  size  may  give  rise  to  coarse  bub- 
bling rales,  and  also  the  presence  of  blood  in  some 
cases  of  profuse  hemorrhage.  In  bronchitis  and 
bronchorrhoea  the  rales  are  heard  on  both  sides  of 
the  chest.  The  bubbling  rales,  whether  coarse  or 
fine,  are  heard  either  with  the  act  of  inspiration  or 
of  expiration,  or  with  both  acts. 

Fine  bubbling  sounds  and  the  so-called  subcrepi- 
tant  Wile  occur  in  various  pathological  connections. 
The  characters  of  the  latter  are  to  be  borne  in  mind 
with  reference  to  the  discrimination  from  the  crepi- 
tant r.'ilc  The  most  distinctive  character  is  the 
moist  sound  or  bubbling;  this  is  sufficiently  appre- 
ciable. Other  characters  arc,  their  occurrence  fre- 
quently, but  not  constantly,  in  expiration  as  well  as 

11* 


126  AUSCULTATION    IN    DISEASE. 

in  inspiration,  and  the  inequality  of  the  fine  bubbling 
sounds. 

The  so-called  subcrepitant  rale,  existing  over  the 
chest  on  both  sides,  is  diagnostic  of  bronchitis  affect- 
ing the  smaller  bronchial  tubes  (capillary  bronchitis), 
when  taken  in  connection  with  other  signs  and  the 
symptoms.  The  rale  exists  on  both  sides,  because 
this,  as  well  as  bronchitis  affecting  the  larger  tubes, 
is  a  bilateral  affection.  The  sign  is  of  great  prac- 
tical value  in  the  diagnosis  of  that  variety  of  bron- 
chitis. The  rale  also  occurs  on  both  sides,  and  is 
more  or  less  diffused  in  pulmonary  oedema.  The 
connection  with  the  latter  affection  is  shown  by  the 
associated  physical  signs,  together  with  the  symp- 
toms. In  so-called  capillary  bronchitis,  the  bubbling 
is  due  to  the  presence  of  thin  mucus,  and  in  pulmo- 
nary oedema  to  serous  transudation  within  the  small 
bronchial  ramifications. 

Fine  bubbling  or  the  so-called  subcrepitant  rale 
has  other  pathological  connections,  as  follows : 

1.  It  occurs  in  lobar  pneumonia  during  the  stage 
of  resolution.  Here  it  is  due  to  the  presence  of 
mucus  from  a  bronchitis  limited  to  the  affected  lobe 
or  lobes,  and,  in  a  measure,  to  liquefied  pneumonic 
exudation.  It  is  considered  as  denoting  commenc- 
ing and  progressing  resolution  in  pneumonia.  Some- 
times it  is  intermingled  with  rales  which  are  more  or 
less  coarse. 

2.  In  circumscribed  pneumonia,  hemorrhagic  in- 
farctus,  and  pulmonary  apoplexy,  the  fine  or  sub- 
crepitant rale,  often  associated  with  those  which  are 
more  or  less  coarse,  denotes  the  presence  of  mucus 
or  of  blood  within  the  bronchial  tubes.     The  rales 


MOIST    BRONCHIAL    RALES.  127 

are  localized  in  space,  or  in  spaces,  corresponding  to 
the  situation  and  extent  of  the  affection. 

3.  During  and  shortly  after  a  haemoptysis,  fine 
rales  limited  to  a  particular  situation  are  sometimes 
heard,  proceeding  from  blood  in  the  small  bronchial 
tubes,  and  indicating  the  situation  of  the  hemorrhage. 

4.  A  purulent  liquid  admits  of  bubbling  much 
more  readily  than  mucus ;  hence,  in  cases  of  chronic 
bronchitis  with  an  expectoration  of  pus,  fine  and 
coarse  bronchial  rales  are  more  frequent  than  in 
acute  bronchitis.  Pus,  also,  may  be  present  within 
bronchial  tubes  of  small  size,  not  as  a  product  of 
bronchitis,  but  from  the  evacuation  of  an  abscess  of 
either  the  pulmonary  parenchyma,  of  the  liver  or 
some  other  adjacent  part,  and  from  perforation  of 
lung  in  some  cases  of  empyema. 

5.  In  the  different  stages  of  phthisis,  moist  bron- 
chial rales  are  usually  present.  The  liquid  in  the 
tubes,  if  the  disease  be  advanced,  is  derived,  in  part, 
from  associated  bronchitis,  and,  in  part,  from  lique- 
fied tuberculous  exudation.  The  bubbling  sounds 
may  be  more  or  less  coarse  or  fine,  and  both  are 
often  intermingled.  Early  in  the  disease,  before 
softening  of  the  exudation  has  taken  place,  fine 
bubbling,  or  the  subcrepitant  rale,  limited  to  the 
summit  of  the  chest,  is  an  important  diagnostic 
sign.  It  belongs  among  the  accessory  physical 
signs  on  which  the  diagnosis  may  depend.  Sere 
the  liquid  is  derived  from  a  coexisting  circum- 
scribed bronchitis. 

In  cases  of  fibroid  phthisis,  or  cirrhosis  of  lung, 
moist   rales,  coarse  and   fine,  arc  generally  more  or 


128  AUSCULTATION    IN    DISEASE. 

less  abundant  and  diffused  over  the  whole,  or  the 
greater  part,  of  the  chest  on  the  affected  side. 

In  the  foregoing  account  of  the  moist  bronchial 
rales,  the  subcrepitant  rale  is  not  reckoned  as  a  sign 
distinct  from  fine  bubbling  sounds.  Inasmuch  as 
the  mechanism  and  the  significance  are  the  same, 
and  it  is  not  easy  to  draw  a  line  of  demarcation 
between  the  two,  the  distinction  is  unimportant.  It 
is  sufficient  to  bear  in  mind  that  very  fine  bubbling 
sounds  are  called  subcrepitant,  because  they  are 
somewhat  analogous  to  the  crepitant  rale.  The 
points  which  distinguish  the  latter  are,  however, 
well  marked,  as  will  appear  when  the  characters  of 
that  sign  are  considered.  The  term  subcrepitant 
gives  rise  to  confusion,  and  there  is  no  advantage  in 
retaining  it  as  the  name  of  a  distinct  sign.  Very 
fine  bubbling  expresses  more  correctly  the  characters 
of  the  sign.  The  moist  rales  are  often  called  mucous 
rales.  This  name  is  obviously  inappropriate,  since, 
not  only  are  the  sounds  produced  by  other  liquids 
than  mucus,  but  other  liquids  are  best  suited  for 
their  production,  especially  in  the  large  and  medium- 
sized  tubes. 

The  several  varieties  of  the  moist  bronchial  rales 
may  be  produced  by  the  injection  of  a  liquid  in 
varying  quantity  into  the  bronchi  of  the  lungs  re- 
moved from  the  body  of  an  animal  of  sufficient  size, 
e.  #.,  of  the  sheep  or  calf,  and  imitating  respiration 
by  means  of  bellows. 

The  moist  bronchial  rales,  whether  coarse  or  fine, 
vary  in  pitch  accordingly  as  the  lung  surrounding 
the  tubes  in  which  they  are  produced  is,  or  is  not, 
solidified.     If  the  lung  be  solidified,  the  pitch   is 


DRY    BRONCHIAL    RALES.  129 

high;  if  there  be  no  solidification,  the  pitch  is  com- 
paratively low.  Thus,  the  pitch  of  the  rales  is  high 
in  the  second  stage  of  pneumonia  and  in  phthisis 
with  considerable  solidification,  whereas  the  pitch 
is  low  in  bronchitis  and  pulmonary  oedema.  If, 
therefore,  the  respiratory  sound  be  suppressed,  it  is 
easy  to  determine  by  the  pitch  of  these  rales  whether 
the  lung  be  solidified  or  not,  and  to  judge  measur- 
ably of  the  degree  of  solidification.  Attention  to 
the  pitch  in  connection  with  these  rales  is  sometimes 
of  value  in  diagnosis. 

Dry  Bronchial  Rales. 

All  adventitious  sounds  which  are  not  moist,  pro- 
duced within  the  air-tubes  below  the  trachea,  are 
embraced  under  the  name  dry  bronchial  rales.  The 
sounds  are  many  and  varied  in  character.  They  are 
often  musical  notes.  Frequently  they  are  sugges- 
tive of  certain  familiar  sounds,  such  as  the  chirpiDg 
of  birds,  the  cry  of  a  young  animal,  snoring  in  sleep, 
cooing  of  pigeons,  humming  of  the  mosquito,  the 
note  of  the  violoncello,  etc.,  etc.  They  are  often 
heard  at  a  distance,  and  characterized  as  wheezing 
sounds.  An  interrupted  or  clicking  sound  is  not 
uncommon.  All  these  varieties  arc  practically  un- 
important, and  it  would  he  a  needless  refinement  to 
consider  particular  varieties  as  distinct  signs.  The 
only  distinction  which  it  is  desirable  to  make  is  into 
tlif  sibilant  and  Bonorous  r&les.  This  distinction  is 
based  od  difference  in  pitch;  sibilant  rSles  are  high, 
and  sonorous  rales  are  low  in  pitch.  Ajb  a  rule,  the 
sibilant    rales    arc    produced    in    the   small    and    the 


130  AUSCULTATION    IN    DISEASE. 

sonorous  rales  in  the  larger  sized  bronchial  tubes. 
The  sounds  may  accompany  either  inspiration  or  ex- 
piration, or  both.  The  sibilant  and  sonorous  rales 
are  often  intermingled.  There  may  be  sibilant  rales 
with  inspiration,  and  sonorous  rales  with  expiration, 
within  the  same  situation.  Moreover,  these  rales 
are  found  often  to  vary  from  minute  to  minute, 
being  at  one  instant  sibilant  and  at  another  sonor- 
ous. Students  are  liable  to  confound  sonorous  rales 
with  bronchial  breathing  and  sometimes  friction- 
sounds. 

The  physical  condition  represented  by  the  dry 
rales  is  diminished  calibre  of  the  air-tubes  at  certain 
points,  and  especially  in  consequence  of  spasm  of 
the  bronchial  muscular  fibres.  The  latter  consti- 
tutes the  essential  pathological  condition  in  a  par- 
oxysm of  asthma;  and  in  this  affection  the  dry  rales 
are  always  marked.  Their  diagnostic  importance 
relates  chiefly  to  asthma.  Both  sibilant  and  sonor- 
ous rales  are  present  and  diffused  over  the  entire 
chest.  Wheezing  sounds  with  expiration  are  heard 
by  the  patient,  and  by  others  at  a  distance.  A 
single  paroxjTsm  of  asthma  affords  an  opportunity 
for  the  student  to  observe  all  the  varieties  and 
fluctuations  of  these  rales.  Taken  in  connection 
with  other  signs  and  the  symptoms,  the  rales  are 
pathognomonic  of  asthma. 

More  or  less  spasm  of  the  bronchial  muscular 
fibres  occurs  in  certain  cases  of  bronchitis,  without 
being  sufficiently  great  and  extensive  to  give  rise  to 
a  paroxysm  of  asthma,  or  even  any  embarrassment 
of  respiration.  Under  these  circumstances  the  rales 
are  less  marked  and  diffused.    An  asthmatic  element 


VESICULAR    OR    CREPITANT    RALE.         131 

may  be  said  to  enter,  more  or  less,  into  these  cases. 
Narrowing  of  bronchial  tubes  by  tenacious  mucus 
which  gives  rise  to  no  bubbling  sounds,  and,  per- 
haps, unequal  swelling  of  the  mucous  membrane, 
may  also  occasion  sibilant  and  sonorous  rales. 

Dry  Wiles  at  the  summit  of  the  chest  are  not 
infrequent  in  cases  of  phthisis  due  to  spasm,  the 
presence  of  mucus,  or  to  swelling  of  the  mucous 
membrane.  They  are  sometimes  quite  annoying  to 
phthisical  patients. 

Clicking  sounds  are  suggestive  of  the  sudden 
separation  of  tenacious  mucus  from  the  walls  of  the 
bronchial  tubes.  These  are  sufficiently  common  in 
bronchitis  and  in  phthisis. 

Vesicular  or  Crepitant  Rale. 

This  is  the  only  vesicular  rale.  It  is  usually  con- 
sidered to  be  produced  within  the  air-vesicles,  but 
probably,  the  terminal  bronchial  tubes  or  bronchioles 
participate  in  its  production. 

It  is  to  be  distinguished  from  very  fine  bubbling 
sounds,  or  the  so-called  subcrepitant  rale.  The 
points  of  distinction  are  as  follows :  The  sounds  are 
not  moist  but  dry;  they  are  crackling,  not  bubbling 
in  character.  They  may  be  defined  to  be  very  fine, 
dry,  crackling  sounds.  This  point  of  difference  is 
very  distinctive.  There  are,  however,  other  differ- 
ential points.  The  crackling  sounds  are  equal, 
whereas*,  fine  bubbling  sounds  are  unequal,  that  is. 
they  give  the  impression  of  bubbles  of  unequal  size. 
The  crepitating  sounds  are  heard  at  the  end  of  the 
inspiratory  act,  and  especially  at  the  end  of  a  forced 


132  AUSCULTATION    IN    DISEASE. 

inspiration,  the  subcrepitant  rale,  on  the  other  hand, 
being  heard  often  with  or  near  the  beginning  of  in- 
spiration, and,  perhaps,  ceasing  before  the  end  of 
the  inspiratory  act.  Another  distinctive  feature  is 
the  abrupt  development  of  the  crepitant  rale ;  there 
is  a  shower  of  crackles,  as  it  were,  at  the  end  of  a 
forced  inspiration.  Finally,  the  rale  is  never  heard 
in  expiration.  The  apparent  exceptions  to  this 
statement  are  instances  in  which  the  crepitant  and 
the  subcrepitant  rale  are  associated.  This  is  not 
very  infrequent,  and,  with  a  practical  knowledge  of 
the  characters  of  each,  it  is  by  no  means  difficult  to 
appreciate  the  combination  of  the  two  signs.  In 
fact,  the  combination  affords  an  excellent  opportunity 
to  illustrate  the  distinctive  characters  of  each ;  the 
line  bubbling  at  or  near  the  beginning  of  inspiration, 
followed  by  the  fine  crackling  at  the  end  of  this  act, 
and  the  former  perhaps  reproduced  in  the  act  of 
expiration. 

There  are  various  modes  in  which  the  crepitant 
rale  may  be  imitated  ;  for  example,  rubbing  together 
a  lock  of  hair  near  the  ear,  throwing  line  salt  upon 
live  coals  or  into  a  heated  vessel,  igniting  a  train  of 
gunpowder,  and  alternately  pressing  and  separating 
the  thumb  and  finger  moistened  with  a  solution  of 
gum  arabic  and  held  near  the  ear.  A  perfect  repre- 
sentation is  aft'orded  by  squeezing  a  piece  of  an 
artificial  preparation  known  as  the  India-rubber 
sponge,  and  observing  the  sound  produced  by  the 
separation  of  the  walls  of  the  interstices  when  the 
piece  expands  from  its  elasticity.  This  preparation 
exemplifies  the  true  mechanism  of  the  sign  as  de- 
scribed, first,  by  the  late  Dr.  Carr,  of  Canandaigua, 


VESICULAR    OR    CREPITANT    RALE.         133 

N.  Y.,  in  an  article  published  in  the  American  Journal 
of  Medical  Sciences,  in  <  )etober,  1842.1  Expansion  of 
the  lungs  of  the  sheep  or  calf,  after  removal  from 
the  body,  the  stethoscope  being  applied  to  the  lung- 
surface,  gives,  in  certain  situations,  a  well-marked 
crepitant  rale. 

The  crepitant  rale  is  the  diagnostic  sign  of  pneu- 
monia. It  very  rarely  occurs  in  any  other  patho- 
logical connection.  Of  all  respiratory  signs,  this  is 
most  entitled  to  be  called  pathognomonic.  It  be- 
longs especially  to  the  first  stage  of  acute  pneumonia. 
It  is  not  invariably  present,  but  it  occurs  in  the 
majority  of  cases  of  acute  pneumonia.  In  the  second 
stage,  or  the  stage  of  solidification,  the  rale  generally 
disappears.  It  not  infrequently  is  reproduced  in  the 
stage  of  resolution,  and  it  is  then  called  the  return- 
ing crepitant  rfile.  In  the  latter  stage  it  is  often 
found  in  combination  with  the  subcrepitant  rale. 
The  practical  value  of  this  sign  relates  chiefly  to  the 
diagnosis  of  pneumonia. 

It  is  stated  that  the  crepitant  rale  is  sometimes 
found  in  cases  of  pulmonary  oedema,  and  during  or 
directly  after  an  attack  of  hemoptysis.  If  it  ever 
occur  in  these  cases,  the  instances  must  be  extremely 
rare.  The  statement  is  perhaps  based  on  the  occur- 
rence of  the  subcrepitant,  this  being  confounded 
with  the  crepitant  rale.  It  occurs  transiently  under 
the  following  circumstances:  A  patient  who  has 
been  confined  for  some  time  in  bed,  lying  on  the 
back,  and  much  enfeebled  with  any  disease,  if  sud- 
denly raised  to  a  sitting  posture  and  auscultated,  a 

'  Yi.ir  article  by  the  author  in  the  New  fork  Monthly  Med. 
Journ.  for  Feb.  1869, 

12 


134  AUSCULTATION    IN    DISEASE. 

crepitant  rale  is  often  found  on  the  posterior  aspect 
of  the  chest  at  the  end  of  a  forced  inspiration.  The 
rale  disappears  after  a  few  forced  inspirations.  It  is 
heard,  not  on  one  side  only,  but  on  both  sides.  The 
explanation  is,  that  during  the  recumbent  posture 
continued  for  some  time,  and  the  patient  breathing 
feebly,  enough  of  the  air-vesicles  and  bronchioles 
become  agglutinated  by  means  of  a  little  sticky 
transudation  to  give  rise  to  crackling  sounds  in  a 
few  forced  inspirations.  It  may  be  of  use  to  men-, 
tion  that  if  the  stethoscope  be  applied  to  the  anterior 
surface  of  a  chest  much  covered  with  hair,  the  move- 
ments of  the  pectoral  extremity  of  the  instrument  in 
the  act  of  inspiration  may  produce  a  sound  identical 
with  the  crepitant  rale. 

A  crepitant  rale  at  the  summit  of  the  chest,  within 
a  circumscribed  space,  is  one  of  the  accessory  signs 
of  phthisis.  It  denotes  a  circumscribed  pneumonia 
which  clinical  experience  shows  to  be  generally 
secondary  to  phthisis ;  hence  the  diagnostic  signifi- 
cance of  the  sign. 

Cavernous  or  Gurgling  Rale. 

A  pulmonary  cavity  of  considerable  size,  contain- 
ing a  certain  quantity  of  liquid,  and  communicating 
freely  with  bronchial  tubes,  furnishes  a  rale  which 
is  characteristic.  The  character  of  the  sound  is  ex- 
pressed as  fully  as  possible  by  the  term  gurgling. 
The  sound  is  produced  by  large  bubbling  and  the 
agitation  of  the  liquid  within  the  cavity.  It  maybe 
compared  to  the  sound  produced  by  the  boiling  of  a 
liquid  in  a  flask  or  large  test-tube.     The  sound  is 


FRICTION-SOUNDS.  135 

sometimes  high  pitched  and  amphoric,  but  generally 
it  is  low  in  pitch.  It  is  heard  with  more  or  less 
intensity  within  a  circumscribed  space  almost  in- 
variably at  or  near  the  summit  of  the  chest;  but,  if 
intense,  the  sound  is  diffused,  and  it  may  be  some- 
times heard  at  a  distance.  Its  diagnostic  importance 
relates  to  the  advanced  stage  of  phthisis.  The  rale 
is  heard  chiefly  or  exclusively  in  the  act  of  inspira- 
tion. It  may  be  produced  by  the  act  of  coughing 
sometimes  with  greater  intensity  than  by  respiration. 

Pleural  Rales— Friction-Sounds — Metallic  Tinkling — 
Splashing. 

The  signs  embraced  under  the  name  pleural  rfdes 
are,  1st.  Sounds  produced  by  the  rubbing  together 
of  the  pleural  surfaces,  and  hence  called  friction- 
sounds;  2d.  Metallic  tinkling;  and  3d.  Splashing 
or  succussion  sounds. 

Friction-Sounds. — Movements  of  the  pleural  sur- 
faces upon  each  other  take  place  in  inspiration  and 
expiration;  but  in  health  these  movements  occasion 
no  sound.  Sounds  are  produced  when  the  surfaces 
are  covered  with  a  recent  fibrinous  exudation  which 
prevents  the  normal  continuous,  unobstructed  move- 
ments, and  when  the  surfaces  are  roughened  with 
dense  lymph  or  other  morbid  products.  The  sounds 
are  gem-rally  interrupted,  that  is,  two,  three,  or 
more  sounds  occur  during  the  act  of  inspiration  or 
expiration,  or  during  both  act8.  The  intensity  of 
the  sounds  varies  nun-li  in  dill*  nut  A  slight 

grazing  sound  only  may  be  beard,  or,  on  the  other 
hand,  the  sounds  may  be  SO  loud  as  to  be  heard  by 


136  AUSCULTATION    IN    DISEASE. 

the  patient  and  by  others  at  a  distance.  The  char- 
acter of  the  sounds  is  variable.  The  slight  rubbing 
or  grazing  character  may  be  imitated  by  placing 
over  the  ear  the  palmar  surface  of  one  hand,  and 
moving  over  its  dorsal  surface  slowly  the  pulpy  por- 
tion of  a  finger  of  the  other  hand.  In  some  instances, 
however,  the  rough  character  of  the  sounds  is  ex- 
pressed by  such  terms  as  rasping,  grating,  and  creak- 
ing. In  these  instances  the  sounds  denote  density 
of  the  morbid  product  which  roughens  the  pleural 
surfaces.  In  connection  with  very  rough  sounds, 
vibration  of  the  walls  of  the  chest,  or  fremitus,  is 
sometimes  perceived  by  palpation. 

Aside  from  the  character  of  the  sounds  as  just 
stated,  they  are  distinguished  by  their  apparent 
nearness  to  the  ear;  they  seem  sometimes  to  be  pro- 
duced upon  the  surface  of  the  chest.  They  are 
sometimes  intensified  by  firm  pressure  of  the  stetho- 
scope upon  the  chest.  After  a  little  practical  knowl- 
edge of  these  sounds  they  can  hardly  be  confounded 
with  any  other  rales. 

Pleuritic  friction-sounds  generally  denote  pleurisy. 
In  cases  of  pleurisy  with  effusion,  slight  rubbing  or 
grazing  is  sometimes  heard  before  much  liquid  ac- 
cumulates within  the  pleuritic  cavity.  The  physical 
conditions,  however,  after  the  effusion  has  been  re- 
moved, are  much  more  favorable  for  the  production 
or  friction-sounds,  and  they  are  often  now  rough  in 
character.  They  may  be  transient,  or  they  may 
continue  for  a  considerable  period,  their  duration 
depending  on  the  arrest  of  the  movements  of  the 
pleural  surfaces  by  means   of  either  agglutination 


METALLIC    TINKLING.  137 

with  lymph,  or  adhesion  from  the  growth  of  areolar 
tissue. 

Pleuritic  friction-sounds  occur  not  infrequently  in 
cases  of  pneumonia,  denoting,  in  this  connection, 
coexisting  pleurisy. 

Slight  rubbing  or  grazing  at  the  summit  of  the 
chest  is  one  of  the  accessory  signs  of  phthisis.  It 
denotes  a  circumscribed,  dry  pleurisy,  which,  as 
clinical  experience  shows,  is  generally  secondary  to 
phthisis,  and  hence  the  diagnostic  significance  of 
the  sign. 

In  the  foregoing  instances  in  which  friction-sounds 
are  stated  to  occur,  their  significance  relates  to 
pleurisy.  In  some  rare  instances  the  sounds  are 
produced  by  miliary  tubercles  or  carcinomatous 
nodules  projecting  beyond  the  plane  of  the  visceral 
pleural  surface,  without  pleuritic  inflammation. 

Metallic  Tinkling. — This  is  a  vocal  as  well  as  a  re- 
spiratory sign.  It  is  also  produced  by  acts  of  cough- 
in--,  and  sometimes  by  the  act  of  deglutition.  The 
name  expresses  the  distinctive  character  of  the  sign. 
It  consists  in  a  series  of  tinkling  sounds  of  a  high- 
pitched,  silvery,  or  metallic  tone.  The  number  of 
sounds  varies  from  a  single  sound,  to  two,  three,  or 
more  sounds,  during  an  act  of  either  inspiration  or 
expiration.  This  sign  may  be  imitated  in  various 
ways,  by  means  of  an  India-rubber  bag  of  consider- 
able size.  Forcing  a  liquid  into  the  bag  with 
Davidson'.-  Byringe,  tapping  the  bag  with  the  finger, 
or  shaking  it,  will  produce  tinkling  sounds.  The 
besl  mode  of  artificial  representation  of  the  sign  is 
to  conned  the  bag  with  a  flexible  tube,  the  latter 
containing  a   lew  drops  of  liquid,  and  blowing  into 

12* 


138  AUSCULTATION    IN    DISEASE. 

the  tube  so  as  to  produce  bubbles  at  the  communi- 
cation of  the  tube  with  the  bag.  In  this  latter  ex- 
periment it  is  not  necessary  that  the  bag  contain  any 
liquid.  It  occurs  irregularly,  that  is,  it  is  not  present 
in  every  act  of  breathing,  but  is  heard  at  variable 
intervals.  It  may  sometimes  be  produced  by  forced, 
when  it  is  not  heard  in  tranquil,  breathing.  It  can 
only  be  confounded  with  tinkling  sounds  sometimes 
produced  within  the  stomach.  The  latter,  however, 
are  easily  discriminated  by  their  situation,  and  the 
absence  of  associated  signs  denoting  the  affections  of 
the  chest  in  which  the  sign  occurs. 

Metallic  tinkling  is  the  sign  of  pneumothorax  with 
perforation  of  lung.  In  the  great  majority  of  the 
cases  in  which  it  is  found,  it  is  diagnostic  of  this 
affection.  It  is,  however,  always  associated  with 
other  physical  signs  corroborative  of  the  diagnosis. 

It  is  a  rare  sign,  in  cases  of  phthisis,  of  a  large 
pulmonary  cavity,  the  conditions  for  its  production 
being  analogous  to  those  in  pneumo-hydrothorax, 
namely,  a  space  of  considerable  size  containing  air, 
the  space  communicating  with  bronchial  tubes. 

Splashing,  or  Succussion  Sounds. — This  sign  is  pro- 
duced by  succussion,  which  is  reckoned  as  one  of 
the  different  modes  of  physical  exploration.  Sounds 
thus  produced  are  not  infrequently  heard  at  some 
distance ;  generally,  however,  succussion  is  practised 
while  the  ear  is  applied  to  the  chest,  so  that  properly 
enough  the  sign  may  be  embraced  among  the  aus- 
cultatory signs,  although  not  produced  by  respiration. 

Splashing  is  pathognomonic  of  either  pneumo- 
hydrothorax  or  pneumo-pyothorax.  It  is  especially 
valuable  as  a  sie;n  of  these  affections  because  it  is 


INDETERMINATE    RALES.  139 

almost  invariably  available.  The  instances  are  ex- 
tremely few  in  which  the  sign  is  wanting  when  air 
and  liquid  are  contained  in  the  pleural  cavity.  It 
is  obtained  by  jerking  the  body  of  the  patient  with 
a  quick,  somewhat  forcible  movement,  the  ear  being 
very  near  to,  or  in  contact  with,  the  chest. 

The  sound  is  like  that  produced  when  a  bottle 
partially  filled  with  liquid  is  shaken.  The  sound  is 
often  high-pitched  and  amphoric  in  quality.  The 
only  liability  to  error  is  in  confounding  with  this 
sign,  splashing  produced  within  the  stomach.  At- 
tention to  other  signs  will  always  protect  against 
this  error. 

Indeterminate  Rales. — Under  this  head  may  be  em- 
braced some  sounds  sufficiently  recognizable,  but 
indeterminate  as  regards  the  rationale  of  their  pro- 
duction and  the  physical  conditions  which  they  rep- 
resent. They  may  be  designated  crumpling  and 
crackling  sounds.  The  former  are  probably  due  to 
pleuritic  rubbing,  and  the  latter  to  the  separation  of 
sxiiie  slightly  adherent  air-vesicles  or  bronchioles. 
Their  diagnostic  value  relates  only  to  the  early  stage 
of  phthisis.  In  conjunction  with  other  signs,  any 
indeterminate  rale,  if  limited  to  the  summit  of  the 
chest,  and  especially  to  one  side,  has  some  weight  in 
the  diagnosis.  Crumpling  and  crackling  sound>. 
however,  are  not  uncommon  in  healthy  persons  at 
the  end  of  forced  inspiration.  The  feet  of  their 
presence  at  both  summits,  and  the  absence  of  other 
morbid  signs,  are  the  grounds  for  n<»t  considering 
them  as  evidence  of  disease.  They  are  found  in 
health  especially  if  the  binaural  Btethoscope  be  em- 
ployed.   Their  diagnostic  significance,  thus,  depends 


140  AUSCULTATION    IN    DISEASE 

on  limitation  to  the  summit  of  the  chest  on  one  side, 
and  association  with  other  signs  pointing  to  incipient 
phthisis. 

The  Vocal  Signs  of  Disease. 

The  vocal  signs  of  disease,  with  the  exception  of 
metallic  tinkling,  which  is  a  vocal  as  well  as  respira- 
tory sign,  may  all  be  considered  as  abnormal  modi- 
fications of  the  normal  vocal  resonance  and  of  the 
normal  bronchial  whisper.  The  student  must,  there- 
fore, be  familiar  with  the  distinctive  characters  of 
these  two  normal  signs  before  he  is  prepared  to  enter 
upon  the  study  of  the  abnormal  modifications  (vide 
pages  90  and  95).  lie  must  bear  in  mind  the  facts 
which  have  been  presented  in  relation  to  the  normal 
vocal  fremitus  (vide  page  90).  The  rules  given  for 
auscultation  of  the  voice  are  also  to  be  observed  (vide 
page  91).  Embracing  the  abnormal  modifications 
of  the  loud  voice,  the  whisper  and  fremitus,  the  fol- 
lowing are  the  signs  to  be  considered :  Broncho- 
phony; Whispering  Bronchophony;  .^Egophony ; 
Increased  Vocal  Resonance ;  Increased  Bronchial 
Whisper;  Cavernous  AVhisper ;  Pectoriloquy;  Am- 
phoric Voice  or  Echo ;  Diminished  and  Suppressed 
Vocal  Resonance;  Diminished  and  Suppressed  Vocal 
Fremitus,  and  Metallic  Tinkling. 

Bronchophony. 

Bronchophony  has  the  same  import  as  bronchial 
or  tubular  respiration.  Like  the  latter  sign,  it  rep- 
resents complete  or  considerable  solidification  of 
lung.  Generally  the  two  signs  are  associated,  but 
either  may  be  present  without  the  other. 


BRONCHOPHONY.  141 

The  characters  which  are  distinctive  of  broncho- 
phony, as  compared  with  the  normal  vocal  resonance, 
are  these:  The  vocal  sound  seems  concentrated,  in 
most  cases  near  the  ear,  and  the  pitch  is  more  or  less 
raised.  These  characters  are  in  contrast  with  the 
diffusion,  distance,  and  lowness  of  pitch  of  the  nor- 
mal vocal  resonance.  The  intensity  of  the  sound  is 
variable ;  it  may  be  greater  or  less  than  the  intensity 
of  the  normal  resonance.  A  concentrated,  high- 
pitched  sound,  however  feeble,  is  not  less  a  sign  of 
complete  or  considerable  solidification  of  lung,  that 
is,  it  is  not  less  bronchophony,  than  when  the  sound 
is  intense. 

Vocal  fremitus  is  always  to  be  discriminated  from 

vocal    resonance.      The    fremitus    associated   with 

bronchophony  may,  or  may  not,  be  greater  than  the 

fremitus  of  health.     Not  infrequently  the  fremitus 

-  than  in  health. 

It  is  to  be  borne  in  mind  that  in  some  healthy 
prisons  bronchophony  exists  at  the  summit  of  the 
chest,  especially  on  the  right  side,  over  the  primary 
bronchus.  Existing  in  this  situation,  it  may  not  be 
abnormal. 

Kepresenting  complete  or  considerable  solidifica- 
tion of  lung,  this  sign  occurs  in  the  different  affec- 
tions in  which  bronchial  or  tubular  respiration  lias 
been  seen  to  occur  [vide  page  107),  namely,  lobar 
pneumonia,  phthisis,  chronic  or  fibroid  pneumonia, 
condensation  of  lung  from  either  pleuritic  effusion, 
the  accumulation  of  air  in  the  pleural  cavity  or  the 
pressure  of  a  tumor,  collapse  of  pulmonary  lobules, 
coagulatioa  of  blood  within  the  air-vesicles,  and  car- 
cinoma of  lung. 


142  AUSCULTATION    IN    DISEASE. 

For  the  production  of  bronchophony,  a  less  degree 
of  solidification  is  requisite  than  for  the  production 
of  bronchial  or  tubular  respiration.  Hence,  bron- 
chophony may  be  associated  with  a  broncho-vesicular, 
as  well  as  with  a  purely  bronchial,  respiration.  This 
is  illustrated  in  the  resolving  stage  of  pneumonia. 
When  resolution  has  progressed  sufficiently  for  the 
bronchial  to  give  place  to  the  broncho-vesicular  res- 
piration, well-marked  bronchophony  is  often  found 
to  continue,  ceasing  at  a  later  period  in  the  resolving 
stage. 

The  apparent  nearness  to  the  ear  of  the  vocal 
sound  in  bronchophony  is  wanting  if  a  certain  quan- 
tity of  liquid  intervene  between  the  solidified  lung 
and  the  walls  of  the  chest  at  the  situation  auscultated. 
The  voice  under  these  conditions  seems  to  be  more 
or  less  distant.  This  difference  is  readily  appre- 
ciated. With  this  apparent  distance  of  the  broncho- 
phonic  voice,  in  some  instances  is  associated  the 
modification  which  is  characteristic  of  another  sign, 
namely,  regophony. 

Whispering  Bronchophony. 

The  characters  of  this  sign  correspond  to  those  of 
the  expiratory  sound  in  the  bronchial  or  tubular 
respiration  (vide  page  107).  The  sound  is  more  or 
less  intensified,  high  in  pitch,  and  tubular  in  quality. 
If  the  patient  pronounce  numerals  in  a  forced  whis- 
per, the  characters  are  generally  more  marked  than 
in  the  expiratory  sound  in  forced  breathing.  The 
significance  of  this  sign  is  the  same  as  that  of  the 
bronchial  or  tubular  respiration,  and  of  broncho- 
phony with  the  loud  voice. 


VOCAL   RESONANCE   AND   FREMITUS.        143 

iEgophony. 

This  sign  is  a  modification  of  bronchophony.  As 
regards  concentration  and  pitch,  it  has  the  characters 
of  bronchophony,  the  distinctive  features  being-  ap- 
parent distance  from  the  ear,  and  treniulousness  or 
a  bleating  tone.  From  the  latter  the  name  is  de- 
rived, the  term  signifying  the  cry  of  the  goat.  The 
characters  which  distinguish  the  sign  from  broncho- 
phony are  readily  enough  appreciated,  and  it  repre- 
sents a  physical  condition  added  to  solidification  of 
lung.  This  physical  condition  is  the  presence  of 
liquid  effusion.  The  sign  is  rarely  present  in  cases 
of  large  effusion.  It  occurs  usually  when  the  chest 
is  about  half  filled  with  liquid,  and  the  lung  at  the 
level  of  the  liquid  is  sufficiently  condensed  to  give 
rise  to  bronchophony.  This  condition,  under  these 
circumstances,  involves  agglutination  of  lung  above 
the  portion  condensed  by  pressure.  The  sign  also 
sometimes  occurs  in  cases  of  pleuro-pneumonia,  the 
solidification  in  these  cases  being  due  to  pneumonic 
exudation.  As  a  sign  of  liquid  effusion  it  possesses 
diagnostic  value,  although,  owing  to  the  fact  that 
the  existence  of  effusion  is  easily  determined  by 
other  signs,  it  may  be  said  to  be  superfluous.  When 
the  person  examined  speaks  with  the  teeth  approxi- 
mated, bronchophony  lias  somewhat  of  the  character 
of  aegophony. 

Increased  Vocal  Resonance  and  Fremitus. 

The  distinctive  character  of  this  sign  is  an  increase 
of  the  intensity  of  the  resonance  without  notable 
change  in   other  respects.      The  resonance  may  be 


144  AUSCULTATION    IN    DISEASE. 

more  or  less  intensified,  but  it  is  distant,  diffused, 
and  comparatively  low  in  pitch  ;  in  other  words,  the 
characters  distinctive  of  bronchophony  are  wanting. 
The  differential  points  between  bronchophony  and 
increased  resonance  should  be  clearly  apprehended, 
bearing  in  mind  that  the  intensity  of  the  sound  in 
bronchophony  may,  or  may  not,  be  greater  than  the 
normal  resonance. 

Increased  vocal  resonance  occurs  when  the  lung 
is  solidified,  the  solidification  not  sufficient  in  degree 
to  produce  bronchophony.  Lung  slightly  or  mod- 
erately solidified  gives  rise  to  an  increase  of  the 
intensity  of  the  resonance  of  the  voice;  if  the  solidi- 
fication become  considerable  or  complete,  broncho- 
phony takes  the  place  of  the  simple  increase  of 
intensity.  Thus,  at  an  early  period  in  pneumonia, 
increased  vocal  resonance  precedes  bronchophony ; 
and  in  the  stage  of  resolution  the  reverse  of  this 
takes  place,  namely,  increased  vocal  resonance  fol- 
lows bronchophony,  the  latter  ceasing  when  resolu- 
tion has  progressed  to  a  certain  extent. 

Contrary  to  what  would  perhaps  be  anticipated  in 
the  instances  just  cited,  the  intensity  of  the  sound 
when  bronchophony  is  present  may  be  not  only  not 
increased,  but  diminished  below  that  of  health ;  that 
is,  in  the  first  stage  of  pneumonia  the  increased  in- 
tensity may  cease  when  bronchophony  occurs,  and 
return  when  bronchophony  disappears. 

Increase  of  the  vocal  resonance  occurs  in  connec- 
tion with  pulmonary  cavities.  Over  a  cavity  of  con- 
siderable size  situated  near  the  superficies  of  the  lung, 
the  vocal  resonance  is  sometimes  extremely  intense 
without  any  bronchophonic  characters.     The  latter, 


VOCAL    RESONANCE    AND    FREMITUS.       145 

if  present,  denote  considerable  solidification  either 
around  the  cavity,  or  between  it  and  the  walls  of  the 
chest.  From  the  presence  or  the  absence  of  bron- 
chophonic  characters  with  greatly  increased  intensity 
of  resonance,  the  auscultator  can  judge  whether  the 
cavity  be,  or  be  not,  in  proximity  to  considerable 
solidification  of  lung. 

Irrespective  of  the  cavernous  stage  of  phthisis,  the 
sign  is  of  diagnostic  importance  in  the  different 
affections  which  involve  moderate  or  slight  solidifi- 
cation of  lung,  namely,  pneumonia  early  in  the  dis- 
ease and  in  the  stage  of  resolution,  phthisis,  over  the 
compressed  lung  in  pleurisy  with  moderate  effusion, 
collapse  of  pulmonary  lobules,  hemorrhagic  infarctus. 
and  carcinoma  of  lung.  Into  the  diagnosis  of  all 
these  affections,  both  bronchophony  and  increased 
vocal  resonance  enter ;  the  former  when  solidifica- 
tion is  considerable  or  complete,  and  the  latter  when 
it  is  slight  or  moderate.  Increased  vocal  resonance 
is  especially  valuable  in  the  diagnosis  of  early  or 
incipient  phthisis.  An  abnormal  resonance,  how- 
ever slight,  at  the  summit  of  the  chest  on  one  side, 
is  an  important  sign  in  that  affection.  In  determin- 
ing an  abnormal  resonance  on  the  right  side,  either 
at  the  summit  or  elsewhere,  allowance  must  always 
be  made  for  the  normally  greater  resonance  on  this 
side. 

Increased  vocal  resonance  has  the  same  import  as 
broncho-vesicular  respiration.  These  two  signs, 
however,  are  not  always  in  the  same  proportion  : 
that  is,  the  characters  of  the  latter  may  be  marked 
out  of  proportion  to  the  amount  of  the  increase  of 
the  vocal  resonance,  and  vice  versd. 

18 


146  AUSCULTATION    IN    DISEASE. 

Increased  vocal  fremitus  generally  accompanies 
increased  vocal  resonance,  and  it  denotes  solidifica- 
tion of  lung.  Fremitus,  however,  and  resonance  are 
not  always  in  equal  proportion,  that  is,  either  may 
be  increased  more  than  the  other.  An  increased 
fremitus  is  sometimes  of  value  in  the  diagnosis  of 
phthisis.  The  greater  fremitus  on  the  right  side  of 
the  chest  is  always  to  be  borne  in  mind,  and  due 
allowance  is  to  be  made  for  this  disparity  in  deter- 
mining that  the  fremitus  is  increased. 

Increased  Bronchial  Whisper. 

The  significance  of  this  sign  is  the  same  as  that  of 
increased  vocal  resonance  and  the  broncho-vesicular 
respiration ;  it  represents  the  same  physical  condition 
as  the  two  latter  signs,  namely,  solidification  of  lung, 
greater  or  less,  but  below  the  degree  requisite  to  give 
rise  to  bronchophony  and  bronchial  respiration.  Its 
diagnostic  application  is,  therefore,  involved  in  the 
same  pulmonary  affections. 

The  characters  of  the  sign  are  those  wThich  belong 
to  the  expiratory  sound  in  the  broncho-vesicular 
respiration.  They  consist,  therefore,  of  increase  of 
intensity,  a  quality  more  or  less  tubular,  and  the 
pitch  raised,  these  modifications  of  the  normal  ex- 
piratory sound  varying  in  degree  between  the 
slightest  appreciable  morbid  change  and  a  close  ap- 
proximation to  the  bronchophonic  whisper.  The 
modifications  in  degree  correspond  to  the  degree  of 
solidification.  To  appreciate  the  characters  of  this 
sign,  it  must  be  studied  in  comparison  with  those  of 
the  normal  bronchial  whisper  in  different  portions 


INCREASED    BRONCHIAL    WHISPER.         147 

of  the  chest.  The  most  important  of  the  diagnostic 
applications  of  the  sign  is  in  cases  of  phthisis  in  its 
early  stage.  In  this  application,  the  points  of  nor- 
mal disparity  between  the  two  sides  of  the  chest  at 
the  summit  are  to  be  borne  in  mind,  and  due  allow- 
ance made  for  them  (vide  page  96.) 

A  greater  intensity  of  the  bronchial  whisper  at  the 
right  than  at  the  left  summit  is  not  evidence  of  dis- 
ease ;  but  greater  intensity  at  the  left  summit  is 
always  abnormal.  As  a  rule,  the  pitch  of  the  nor- 
mal bronchial  whisper  at  the  left,  is  higher  than  that 
at  the  right,  summit;  if,  therefore,  with  a  greater 
intensity  of  the  whisper  at  the  right  summit,  it  be  a 
matter  of  doubt  whether  it  denote  disease  or  not, 
when  the  pitch  is  higher  at  this  summit  it  is  to  be 
considered  as  morbid. 

Cavernous  Whisper. — The  characters  distinctive  of 
the  cavernous  whisper  are  those  of  the  expiratory 
sound  in  the  cavernous  respiration,  namely,  lowness 
of  pitch,  and  the  quality  blowing,  that  is,  non-tubular. 
The  intensity  of  the  sound  is  variable.  It  is  limited 
to  a  circumscribed  space  corresponding  to  the  situa- 
tion and  size  of  the  cavity.  Xot  infrequently  the 
characters  of  the  sign  are  brought  into  contrast  with 
those  of  whispering  bronchophony,  or  increased 
bronchial  whisper,  these  latter  .signs  existing  in  close 
proximity,  and  representing  solidification  of  lung  in 
the  immediate  neighborhood  of  the  cavity.  The 
diagnostic  application  of  this  sign  is  chiefly  to  ad- 
vanced phthisi-. 

Pectoriloquy. — In  pectoriloquy,  not  merely  the 
voice,    but    the    speech,    is   transmitted    through    the 

chest:  the  auscultator  recognizes  words  uttered  by 


148  AUSCULTATION    IN     DISEASE. 

the  patient.  The  student,  however,  must  not  expect 
to  be  able  to  carry  on  a  conversation  with  the  patient 
by  means  of  the  stethoscope.  Often  single  words 
only  can  be  recognized.  To  make  sure  that  these 
are  transmitted  through  the  chest,  care  must  be 
taken  to  exclude  their  direct  transmission  from  the 
patient's  mouth,  and  the  auscultator  should  not 
know  beforehand  the  words  which  are  to  be  spoken. 
If  these  rules  be  not  observed,  the  auscultator  may 
err  in  supposing  that  the  words  are  transmitted 
through  the  chest.  When  auscultation  is  practised 
with  one  ear,  the  other  should  be  closed. 

The  speech  with  either  the  loud  or  the  whispered 
voice  may  be  transmitted,  the  latter,  distinguished 
as  whispering  pectoriloquy,  being  much  more  fre- 
quent than  the  former;  moreover,  in  determining 
whispering  pectoriloquy,  there  is  less  liability  to 
error  in  mistaking  the  perception  of  words  coming 
directly  from  the  mouth  for  the  transmission  through 
the  chest.  In  the  production  of  this  sign,  much  de- 
pends on  the  distinctness  with  which  words  are 
articulated  by  the  patient.  Normal  pectoriloquy  at 
the  anterior  superior  portion  of  the  chest  is  some- 
times observed. 

Pectoriloquy  belongs  among  the  cavernous  signs; 
but  it  is  by  no  means  exclusively  the  sign  of  a  cavity; 
the  speech  may  also  be  transmitted  by  solidified  lung. 
It  is  easy  to  determine  in  any  case  whether  the  sign 
denotes  a  cavity  or  solidified  lung.  If,  with  trans- 
mitted speech,  the  voice  have  the  characters  of 
bronchophony,  the  sign  represents  solidification  of 
lung;  if,  on  the  other  hand,  the  characters  of  bron- 
chophony be  wanting,  the  sign  represents  a  cavity. 


INCREASED  BRONCHIAL  WHISPER.    149 

These  statements  apply  equally  to  the  loud  and  to 
the  whispered  voice.  Of  course,  associated  signs 
will  he  likely  to  show  whether  a  cavity  exists  or 
not.  It  is  to  be  added  that  a  cavity  and  solidification 
of  lung  existing  together,  may  conjointly  be  con- 
cerned in  the  production  of  the  sign. 

Amphoric  Voice  or  Echo. — This  sign  is  identical  in 
character  with  amphoric  respiration,  with  which  it 
is  usually  associated  {vide  page  115).  The  amphoric 
intonation  may  accompany  the  loud  voice  and  the 
whisper;  generally,  it  is  more  appreciable  or  marked 
with  the  latter.  Its  significance  is  the  same  as  that 
of  amphoric  respiration.  As  a  rule,  it  represents 
the  conditions  in  pneumothorax,  namely,  a  large 
space  filled  with  air  and  perforation  of  lung.  In  this 
affection  it  is  associated  with  other  signs  which  suffice 
for  a  prompt  and  positive  diagnosis.  It  is  not  inva- 
riably found  in  pneumothorax,  and  it  may  be  present 
in  a  case  at  one  time  and  wanting  at  another  time, 
its  production  being  dependent  on  the  perforation 
being  above  the  level  of  liquid,  if  the  latter  exist, 
and  on  the  bronchial  tubes  leading  to  the  perfora- 
tion being  unobstructed.  When  not  associated  with 
other  signs  which  are  diagnostic  of  pneumothorax, 
it  denotes  a  phthisical  cavity  of  considerable  size. 
It  is  not  infrequently  a  sign  of  a  phthisical  cavity 
with  rigid  walls  and  communicating  freely  with 
bronchial  tubes.  It  has  this  significance  whenever 
pneumothorax  can  be  excluded;  and  the  associated 
signs  in  tlic  hitler  affection  are  such  that  its  exclu- 
sion is  always  practicable 

The   amphoric  sound   sometimes  is  observed  to 

18 


150  AUSCULTATION    IN    DISEASE. 

follow  the  oral  voice ;  hence,  the  name  amphoric 
echo. 

Diminished  and  Suppressed  Vocal  Resonance. — 
Diminution  and  suppression  of  the  normal  vocal 
resonance  occur  especially  when  the  pleural  cavity 
contains  either  liquid  or  air.  Whenever  the  lungs 
are  not  in  contact  with  the  walls  of  the  chest,  the 
vocal  resonance,  as  a  rule,  is  either  notably  lessened 
or  wanting.  The  sign  is,  therefore,  of  value  in 
diagnosis  in  cases  of  pleurisy  with  effusion,  em- 
pyema, hydrothorax,  and  pneumothorax.  When 
the  pleural  cavity  is  partially  filled  with  liquid,  there 
is  diminution  or  suppression  of  the  resonance  from 
the  level  of  the  liquid  downward;  and  generally, 
just  above  the  level  of  the  liquid,  the  resonance  is 
increased,  owing  to  condensation  of  the  lung.  The 
sign  is  well  illustrated  by  the  contrast  in  such  cases 
above  and  below  the  level  of  the  liquid.  As  a  rule, 
the  changes  of  the  level  of  the  liquid  with  changes 
in  position  of  the  body,  may  be  as  well  demonstrated 
by  means  of  vocal  resonance  as  by  percussion.  Ex- 
ceptionally, however,  this  rule  is  not  available. 

The  practical  importance  of  diminished  and  sup- 
pressed vocal  resonance  relates  chiefly  to  the  diag- 
nosis of  the  affections  just  named.  In  this  application, 
however,  the  associated  signs  must  be  taken  into 
account.  The  vocal  resonance  may  be  diminished 
or  suppressed  when  the  lung  is  completely  solidified 
in  the  second  stage  of  pneumonia;  also  in  pulmonary 
oedema,  and  over  the  site  of  an  intra-thoracic  tumor. 

If  the  vocal  resonance  be  normal,  that  is,  neither 
increased  nor  diminished,  we  are  warranted  in  ex- 
cluding all  the  affections  which  have  been  named ; 


DIMINISHED    VOCAL    RESONANCE.  151 

the  exceptional  instances  are  so  rare  that,  practically, 
they  may  be  disregarded. 

Diminished  vocal  resonance  may  be  found  over  a 
pulmonary  abscess  before  the  pus  is  evacuated,  and 
over  a  cavity  tilled  with  liquid.  The  sign  is  then 
limited  to  a  circumscribed  space.  Obstruction  of  a 
bronchial  tube  diminishes  resonance  in  so  far  as  the 
column  of  air  is  a  medium  for  the  conduction  of 
vocal  sound. 

The  normal  disparity  between  the  two  sides  of  the 
chest  is  to  be  borne  in  mind  with  reference  to  dim- 
inished or  suppressed,  as  well  as  to  increased,  vocal 
resonance ;  otherwise  the  relative  feebleness  of  the 
resonance  on  the  left  side  in  health  might  be  con- 
sidered to  be  morbid.  The  normally  greater  reso- 
nance on  the  right  side  renders  it  easier  to  determine 
a  morbid  diminution  on  this  than  on  the  left  side. 

Diminished  and  Suppressed  Vocal  Fremitus. —  This 
tactile  sensation,  which  is  appreciable  in  ausculta- 
tion, as  a  rule,  is,  on  the  one  hand,  increased,  and, 
on  the  other  hand,  diminished  or  suppressed,  under 
the  same  physical  conditions  which  occasion  corre- 
sponding modifications  of  the  vocal  resonance. 
Diminished  or  suppressed  vocal  fremitus,  therefore, 
has  the  same  diagnostic  significance  as  diminished 
or  suppressed  vocal  resonance.  Usually  the  abnor- 
mal modifications  of  resonance  and  fremitus  so 
together,  but  cither  may  be  out  of  proportion  to  the 
other.  The  signs  relating  to  fremitus  thus  corrobo- 
rate those  relating  to  resonance.  The  former  may 
be  marked  when  the  latter  admit  of  doubt,  dim- 
inished or  suppressed  fremitus  is  valuable  in  the 
diagnosis  of  pleurisy  with  effusion,  empyema,  hydro- 


152  AUSCULTATION    IN     DISEASE. 

thorax,  and  pneumothorax.  It  is,  however,  to  be 
noted  that  in  exceptional  instances  the  fremitus 
persists  over  the  site  of  liquid  within  the  chest. 

With  regard  to  vocal  fremitus,  as  to  vocal  reso- 
nance, it  is  essential  to  take  cognizance  of  the  normal 
disparity  between  the  two  sides  of  the  chest,  the 
greater  relative  fremitus,  on  the  right  side,  as  a  rule, 
being  no  less  marked  than  the  relatively  greater 
resonance  on  that  side. 

Metallic  Tinkling. — This  sign  has  the  same  char- 
acters when  it  accompanies  either  the  loud  or  whis- 
pered voice,  as  when  it  is  heard  with  respiration, 
and,  of  course,  it  has  the  same  significance  [vide 
page  99).  It  may  be  more  marked  with  acts  of 
speaking  than  with  the  respiratory  acts. 

Signs  obtained  by  Acts  of  Coughing  or  Tussive  Signs. 

Acts  of  coughing  may  be  made  subservient  to 
auscultation  of  respiratory  sounds  in  two  ways : 
First,  by  the  removal  of  temporary  obstruction  from 
the  accumulation  of  mucus  within  bronchial  tubes. 
If  the  respiratory  murmur  be  diminished  or  sup- 
pressed over  a  portion  or  the  whole  of  one  side  of 
the  chest,  sometimes  an  act  of  coughing  effects  dis- 
lodgement  of  a  mass  of  mucus  from  either  a  primary 
bronchus  or  one  of  its  subdivisions,  and  the  normal 
murmur  is  at  once  restored.  The  dependence  of  the 
morbid  sign  upon  a  temporary  obstruction  is  thus 
demonstrated. .  Second,  by  an  act  of  coughing  more 
air  is  expelled  than  by  an  ordinary  expiration,  and 
in  the  following  inspiration  the  vesicles  have  a  wider 
range  of  expansion,  giving  rise  to  a  proportionately 
loud  inspiratory  sound  ;  hence,  the  characters  of  this 


COUGHING    OK    TUSSIVE    SIGNS.  153 

sound  are  more  pronounced  and  can  be  better  studied. 
For  these  two  objects  it  is  often  advisable  to  request 
the  patient  to  cough  with  a  certain  degree  of  force. 

Acts  of  coughing,  moreover,  give  rise  to  ausculta- 
tory signs  which  have  their  analogues  in  signs 
obtained  by  respiration  and  the  voice.  These  tussive 
signs  are  of  less  value  than  the  respiratory  and  vocal 
signs,  and  in  most  cases,  owing  to  the  latter  being 
sufficient  for  diagnosis,  they  may  be  said  to  be  super- 
fluous; nevertheless,  they  may  be  observed  some- 
times with  advantage.  When  the  conditions  are 
present  which  are  represented  by  bronchial  respira- 
tion, bronchophony  and  the  bronchophonic  whisper, 
sounds  are  obtained  which  correspond  to  these  in 
their  characters.  The  cough  is  then  said  to  be 
bronchial.  With  the  stethoscope  applied  over  an 
empty  cavity  of  some  size,  situated  near  the  surface 
of  the  lung,  the  ear  receives  with  acts  of  coughing  a 
concussion  or  shock  which  is  sometimes  so  forcible 
as  to  be  painful.  This  corresponds  to  an  intense 
vocal  resonance.  Limited  to  a  circumscribed  space, 
it  is  a  highly  significant  cavernous  sign.  It  may  be 
present  when  the  cavernous  respiration  is  wanting. 
A  low-pitched  blowing  sound  corresponds  to  the  ex- 
piratory sound  in  the  cavernous  respiration  and  the 
cavernous  whisper.  An  amphoric  intonation  may 
be  heard  with  acts  of  coughing,  which  corresponds 
to  amphoric  respiration  and  amphoric  voice.  This 
sign  is  sometimes  more  marked  with  cough  than 
with  the  breathing  and  voice.  Cavernous  gurgling 
may  also  he  obtained  more  distinctly  with  cough 
than  with  respiration.  Finally,  metallic  tinkling 
not  infrequently  accompanies  act-  of  coughing. 


CHAPTER  VI. 

THE  PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE 
RESPIRATORY  ORGANS. 

Affections  of  the  larynx  and  trachea — Bronchitis  seated  in  large  bron- 
chial tubes — Bronchitis  seated  in  small  bronchial  tubes,  or  capillary 
bronchitis — Collapse  of  pulmonary  lobules — Lobular  pneumonia — 
Asthma — Pulmonary  or  vesicular  emphysema— Pleurisy,  acute  and 
chronic  — Empyema  — -Hydrothorax  — Pneumothorax  — Pneumohydro- 
thorax — Pneumo-pyothorax — Acute  lobar  pneumonia — Circumscribed 
pneumonia — Embolic  pneumonia — Hemorrhagic  infarctus — Pulmonary 
ap.oplexy — Pulmonary  gangrene — Pulmonary  wdema — Carcinoma  of 
lung — Tumor  within  the  chest — Acute  miliary  tuberculosis — Pulmonary 
phthisis — Fibroid  phthisis,  interstitial  pneumonia,  or  cirrhosis  of  lung 
— Diaphragmatic  hernia. 

In  the  preceding  chapters  the  physical  conditions 
incident  to  the  morbid  changes  occurring  in  the 
affections  of  the  respiratory  organs  have  been  enu- 
merated, and  the  physical  signs,  obtained  by  per- 
cussion and  auscultation,  representing  these  condi- 
tions, have  been  considered,  severally,  as  regards 
their  distinctive  characters  and  their  significance. 
The  object  of  this  chapter  is  to  group  the  physical 
conditions  embraced  in  the  different  diseases  of  the 
respiratory  system  respectively,  together  with  the 
representative  signs  on  which  rests  the  physical 
diagnosis  of  each  of  the  diseases.  The  scope  of  this 
manual  is  limited  to  the  physical  diagnosis  of  these 
affections ;  but  the  fact  is  not  to  be  lost  sight  of  that 
in  practical  medicine  physical  signs  are  not  to  be 


AFFECTIONS  OF  LARYNX  AND  TRACHEA    155 

disassociated  from  symptoms  and  pathological  laws. 
An  exclusive  reliance  on  physical  signs  would  lead 
to  errors  in  diagnosis,  although,  doubtless,  errors 
more  important  and  more  frequent  necessarily  occur 
when  the  practitioner  ignores  percussion  and  auscul- 
tation. The  signs  furnished  by  percussion  and 
auscultation  only  have  been  thus  far  considered,  but 
in  grouping  these  in  this  chapter,  signs  obtained  by 
other  methods  of  physical  exploration  will  be  em- 
braced in  so  far  as  they  enter  into  the  diagnosis  of 
the  different  diseases  of  the  respiratory  system. 
These  different  diseases  will  be  taken  up  separately 
with  the  exception  of  those  seated  in  the  larynx  and 
trachea.  With  reference  to  physical  signs,  the 
laryngeal  and  tracheal  affections  may  be  considered 
collectively. 

Affections  of  the  Larynx  and  Trachea. 

The  physical  signs  referable  to  the  chest  in  dis- 
eases of  the  larynx  and  trachea,  denote  more  or  less 
obstruction  to  the  free  passage  of  air  through  these 
sections  of  the  air-tubes.  The  obstruction  in  the 
different  diseases  involves  different  pathological 
conditions.  Spasm  of  the  glottis  is  one  of  these 
conditions,  constituting  the  affections  known  as 
laryngismus  stridulus  and  spasmodic  croup,  occur- 
ring also  as  a  pathological  element  in  laryngitis,  and 
sometimes  in  connection  with  aneurism,  or  a  tumor 
of  some  kind,  involving  the  recurrent  laryngeal 
nerve.  Another  pathological  condition  is  the  op- 
posite of  this,  namely,  paralysis  of  the  muscles  of  the 
glottis,  the  vocal  chords  remaining  flaccid,  and  ap- 


15G  PHYSICAL    DIAGNOSIS 

proximating  during  inspiration.  Other  pathological 
conditions  are,  oedema  of  the  glottis,  swelling  of  the 
membrane  at  the  glottis  in  laryngitis,  together  with, 
in  the  adult,  submucous  infiltration,  diphtheritic 
exudation,  cicatrization  of  ulcers,  morbid  growths, 
and  the  presence  of  foreign  bodies. 

In  the  affections  involving  the  foregoing  patholo- 
gical conditions,  percussion  and  auscultation  are  of 
use,  first,  by  enabling  the  physician  to  exclude  all 
diseases  within  the  chest.  The  absence  of  signs 
showing  the  existence  of  pulmonary  diseases  renders 
it  certain  that  the  symptoms  denoting  embarrassment 
of  respiration  are  referable  to  the  larynx  or  trachea. 
Second,  by  means  of  auscultation  the  amount  of  ob- 
struction may  be  determined  more  accurately  than 
by  the  subjective  symptoms.  The  amount  of  ob- 
struction is  represented  by  a  proportionate  weakening 
of  the  vesicular  murmur.  This  is  more  reliable  as 
regards  determining  a  dangerous  amount  of  obstruc- 
tion than  the  sense  of  the  want  of  air  or  the  suffering 
of  the  patient.  The  degree  of  diminution  of  the 
vesicular  murmur  is  determinable  with  the  more 
accuracy  the  better  the  auscultator  is  acquainted 
with  the  normal  intensity,  that  is,  the  intensity  prior 
to  the  occurrence  of  obstruction.  With  this  knowl- 
edge, the  weakening  of  the  murmur  is  a  correct 
criterion  of  the  amount  of  obstruction.  In  all  the 
pathological  conditions  named,  the  respiratory  mur- 
mur is  more  or  less  diminished  in  intensity  on  both 
sides  of  the  chest;  there  are  no  signs  obtained  by 
percussion,  nor  do  vocal  resonance  or  fremitus  offer 
anything  distinctive. 

In  cases  of  considerable  or  great  obstruction  during 


BRONCHITIS  IN  LARGE  BRONCHIAL  TUBES.  157 

inspiration,  inspection  furnishes  marked  signs.  The 
expansion  of  the  chest  on  both  sides  is  restricted, 
the  lower  part  of  the  chest  is  contracted  in  the  act 
of  inspiration,  and  in  this  act  the  soft  parts  above 
the  clavicles  are  depressed.  The  contrast  between 
theseabnormal  movements  and  the  normal  thoracic 
movements  of  the  patient  is  striking  and  distinctive. 
An  important  application  of  auscultation  is  the 
localization  of  a  foreign  body  which  has  been  inhaled. 
If  the  vesicular  murmur  on  both  sides  be  more  or 
less  weakened,  the  foreign  body  must  be  situated  in 
either  the  larynx  or  the  trachea.  If,  on  the  other 
hand,  the  vesicular  murmur  be  weakened  or  sup- 
pressed on  one  side,  and  increased  on  the  other  side, 
the  body  is  lodged  in  a  primary  bronchus.  The 
importance  of  this  application  of  auscultation  before 
opening  the  trachea  to  remove  a  foreign  body  is 
sufficiently  obvious.  The  situation  of  a  foreign  body 
may  be  changed  from  one  bronchus  to  the  other  by 
an  act  of  coughing,  even  after  an  operation  has  been 
commenced;  this  is,  of  course,  at  once  determinable 
by  auscultation. 

Bronchitis  Seated  in  Large  Bronchial  Tubes. 

In  bronchitis,  either  acute  or  chronic,  as  it  is  ordi- 
narily presented  in  practice,  the  inflammation  is 
seated  in  the  large  bronchial  tubes,  in  many  cases 
probably  not  extending  beyond  the  primary  and 
secondary  bronchi.  The  physical  conditions  are, 
more  or  less  swelling  of  the  mucous  membrane,  this, 
however,  not  being  sufficient  to  occasion  any  notable 
obstruction  to  the  free  passage  of  air,  and  the  pres- 
ence, in  differenl  cases,  in  greater  or  less  quantity, 

1 1 


158  PHYSICAL    DIAGNOSIS. 

of   mucus,    muco-purulent    matter,   pure  pus,   and 
serum. 

The  physical  diagnosis  involves  negative  rather 
than  positive  points;  in  other  words,  the  diseases 
from  which  bronchitis  is  to  be  differentiated  are  ex- 
cluded by  the  absence  of  their  diagnostic  signs. 
These  diseases  are  pneumonia,  pleurisy,  and  phthisis. 
Each  of  these  is  characterized  by  the  presence  of 
signs,  the  absence  of  which  warrants  its  exclusion. 
In  bronchitis  there  is  no  disparity  between  the  two 
sides  of  the  chest  in  the  resonance  obtained  by  per- 
cussion, nor  in  vocal  resonance,  the  bronchial  whis- 
per, and  fremitus.  The  swelling  of  the  bronchial 
mucous  membrane  may  cause  some  diminution  of 
the  intensity  of  the  vesicular  murmur,  but  as  the 
affection  is  bilateral,  and  the  bronchial  tubes  on  each 
side  are  affected  equally,  both  in  degree  and  extent, 
no  appreciable  disparity  in  this  respect  between  the 
two  sides  is  caused  by  this  physical  condition. 
Weakening  or  suppression  of  the  murmur  over  an 
area  greater  or  less,  may  be  caused  by  bronchial 
obstruction  from  a  plug  of  mucus.  This  obstruction 
is  sometimes  removed  by  an  act  of  expectoration, 
after  which  the  murmur  is  found  to  have  returned, 
or  to  have  regained  its  normal  intensity. 

The  foregoing  points,  taken  in  connection  with 
the  history  and  symptoms,  suffice  for  the  diagnosis. 
Signs  due  directly  to  the  disease  represent  diminished 
calibre  of  the  tubes  at  certain  points  from  swelling 
of  the  membrane,  adhesive  mucus,  and  spasm  of 
bronchial  muscular  iibres.  These  signs  are  the  dry 
bronchial  rales.  They  are  rarely  prominent,  and 
are  oftener  absent  than  present,  if  the  bronchitis  be 


CAPILLARY    BRONCHITIS.  159 

unaccompanied  by  asthma;  hence,  they  are  of  little 
value  in  the  diagnosis.  Other  siems  are  the  bubbling 
sounds  or  the  moist  bronchial  rales.  In  acute  bron- 
chitis these  are  oftener  absent  than  present.  They 
occur  when  liquid  morbid  products  within  the  tubes 
are  unusually  abundant,  or  when  the  removal  of 
these  is  with  difficulty  effected  by  expectoration  in 
consequence  of  muscular  debility  or  other  causes. 
These  rades  are  abundant  and  loud  in  proportion  as 
the  liquid  within  the  tubes  is  either  muco-purulent, 
purulent,  or  serous  in  character.  They  are  more  or 
less  coarse  in  proportion  to  the  size  of  the  tubes  in 
which  the  bubbling  takes  place. 

The  diagnostic  points,  negative  and  positive,  which 
have  been  stated,  are  alike  applicable  to  acute  and 
chronic  bronchitis,  it  being,  of  course,  understood 
that  the  affection  is  primary,  that  is,  not  secondary 
to  some  other  pulmonary  disease. 

If  the  bronchitis  be  unaccompanied  by  solidifica- 
tion of  lung,  the  moist  rales  which  may  be  present 
are  low  in  pitch.  The  pitch  is  raised  if  there  be 
solidified  lung  surrounding  or  adjacent  to  the  tubes 
in  which  the  moist  rales  are  produced. 

Bronchitis  Seated  in  Small  Bronchial  Tubes— Capillary 
Bronchitis — Collapse  of  Pulmonary  Lobules — Lobular 
Pneumonia. 

Inflammation  extending  into  the  small  tubes 
(capillary  bronchitis)  occasions  in  these  the  same 
physical  conditions  which  arc  incident  to  bronchitis 
affecting  tubes  of  large  size,  uamely,  swelling  of  the 
membrane,  ami  the  presence  of  liquid  morbid  pro- 
ducts.    The  latter  arc  not  as  easily  removed  by  ex- 


160  PHYSICAL    DIAGNOSIS. 

pectoration  as  when  they  are  within  large  tubes, 
and,  therefore,  they  are  constantly  present  in  greater 
or  less  quantity.  These  conditions  in  small  tubes 
involve  obstruction  to  the  free  passage  of  air  to  and 
from  the  air-vesicles ;  hence,  the  vast  difference  as 
regards  the  symptoms,  the  suffering,  and  the  danger. 
The  affection  is  bilateral,  a  fact  greatly  enhancing 
the  gravity  of  the  affection.  An  incidental  physical 
condition  is  solidification,  generally  in  disseminated 
portions  of  lung,  the  latter  varying  in  number  and 
size.  These  portions  of  solidified  lung  denote  either 
collapse  of  pulmonary  lobules  or  lobular  pneumonia, 
or  both  in  conjunction.  To  this  incidental  affection, 
German  writers  apply  the  name  "  Catarrhal  pneu- 
monia." Of  course,  any  discussion  of  pathological 
questions  suggested  by  these  names  would  be  here 
out  of  place.  With  reference  to  diagnosis  it  is  to  be 
borne  in  mind  that  the  solidified  portions  of  lung  in 
cases  of  bronchitis  seated  in  small  tubes  are  espe- 
cially situated  in  the  lower  lobes.  Another  inci- 
dental physical  condition  is  temporary  dilatation  of 
the  air-cells,  or  vesicular  emphysema,  seated  in  the 
upper  lobes.  Both  of  these  incidental  conditions 
are  bilateral,  like  the  bronchitis  with  which  they  are 
connected.  Collapse  of  pulmonary  lobules,  or  lobu- 
lar pneumonia,  or  both,  and  emphysema  occur  in 
only  a  certain  proportion  of  the  cases  of  bronchitis 
seated  in  small  tubes.  The  signs,  therefore,  admit 
of  a  division  into  those  which  relate,  1st,  to  the 
bronchitis,  and,  2d,  to  these  incidental  affections. 
With  reference  to  the  diagnosis,  the  fact  is  to  be 
borne"  in  mind  that  bronchitis  seated  in  small  tubes 
occurs  chiefly  in  children  and  the  aged. 


CAPILLARY    BRONCHITIS.  161 

The  physical  diagnosis  of  bronchitis  seated  in 
small  tubes  rests  on  negative  points,  together  with 
a  positive  sign  which  is  uniformly  present.  This 
sign  is  the  fine  moist  bronchial  or  the  so-called  sub- 
crepitant  rale,  present  on  both  sides  and  diffused 
over  the  chest.  The  bubbling  sounds  are  to  be  dis- 
tinguished from  the  fine  dry  crackling  sounds  or  the 
crepitant  rale,  to  the  characters  of  which  the  former 
in  some  measure  approximate. 

The  bronchitis  gives  rise  neither  to  dulness  on 
percussion,  nor  to  any  notable  change  in  vocal  reso- 
nance, or  fremitus.  The  respiratory  murmur,  if  not 
obscured  by  rales,  is  weakened  on  both  sides.  Irre- 
spective of  being  drowned  by  rales,  it  may  be  sup- 
pressed by  the  amount  of  bronchial  obstruction. 
These  are  the  negative  points  in  the  diagnosis.  In 
pulmonary  oedema,  fine  moist  bronchial  rfiles  are 
present  on  both  sides,  but  in  this  affection  there  is 
notable  dulness  on  percussion,  and  the  affection 
occurs  in  certain  pathological  connections,  namely, 
with  mitral  stenosis,  and  disease  of  the  kidneys. 
Acute  tuberculosis  may  present  the  moist  bronchial 
rales  with  the  negative  points  which,  in  connection 
with  symptoms,  characterize  bronchitis  seated  in  the 
small  tubes.  The  differentiation  is  to  be  based  on 
differences  pertaining  to  the  history  and  duration, 
together  with  the  age  of  the  patient. 

The  coexistence  of  the  incidental  affections, 
namely,  collapse  of  pulmonary  lobules,  or  Lobular 
pneumonia,  and  vicarious  emphysema,  occasions 
additional  signs,  [f  the  solidified  portions  oi  lung 
In-  considerable  in  either  number  or  size,  there  will 
bedulnese  on  percussion  in  circumscribed  situations 

14* 


162  PHYSICAL    DIAGNOSIS. 

on  the  posterior  aspect  of  the  chest.  This  will  be 
found  on  both  sides,  but  perhaps  more  marked  on 
one  side.  Broncho-vesicular  or  the  bronchial  respira- 
tion may  be  present,  together  with  the  vocal  signs 
of  solidification,  namely,  either  increased  vocal  reso- 
nance, or  bronchophony,  and  increased  vocal  fre- 
mitus. The  moist  rSles  produced  within  solidified 
portions  of  lung  are  high  in  pitch,  whereas,  if  solidi- 
fication do  not  exist,  these  rales  are  comparatively 
low  in  pitch.  The  existence  of  solidification  at  any 
point  may  be  determined  by  the  pitch  of  the  rales, 
as  well  as  by  the  foregoing  respiratory  and  vocal 
signs. 

"When  there  are  emphysematous  lobules  on  the 
anterior  aspect  of  the  chest  in  the  upper  and  middle 
regions,  on  both  sides,  the  resonance  on  percussion 
is  vesiculotympanitic,  the  respiratory  murmur  weak- 
ened or  suppressed,  and  the  rhythm  altered — in 
short,  the  combination  of  signs  which  will  be  stated 
under  the  head  of  emphysema. 

In  the  cases  in  which  the  bronchitis  occasions 
great  obstruction  in  the  small  tubes,  and,  still  more, 
if  collapse  of  lobules,  or  lobular  pneumonia  and 
vicarious  emphysema  occur,  important  signs  are  ob- 
tained by  inspection.  The  anterior  portion  of  the 
chest  remains  expanded,  and  retraction  of  the  lower 
part  of  the  chest  takes  place  in  the  acts  of  inspiration. 

Asthma. 

The  pathologico-physical  condition  in  a  paroxysm 
of  asthma,  is  obstruction  in  the  small  bronchial 
tubes  attributable  to  spasm  of  the  bronchial  muscu- 
lar fibres.     With  this  condition  is  associated  a  tern- 


ASTHMA.  163 

porary  vesicular  emphysema,  which  exists  often  as 
a  "persistent  affection  in  persons  who  are  subject  to 
asthma.  If  the  emphysematous  condition  already 
exist,  it  is  increased  during  the  paroxysm  of  asthma. 
Bronchitis  generally  coexists,  either  as  a  transient 
or  a  chronic  affection.  In  an  asthmatic  paroxysm, 
therefore,  there  are  present  the  signs  which  are 
proper  to  asthma,  together  with  those  of  emphysema, 
and  the  associated  bronchitis  may  also  occasion  ad- 
ditional signs. 

The  physical  diagnosis  of  asthma,  like  that  of 
bronchitis  seated  in  small  tubes,  is  based  on  nega- 
tive points  taken  in  connection  with  a  sign  which  is 
invariably  present,  namely,  dry  bronchial  rales. 
These  rules  are  more  or  less  intense,  and  they  are 
diffused  over  the  entire  chest.  They  are  generally 
heard  at  a  distance.  The  sibilant  and  sonorous 
varieties  are  mingled,  and  they  are  constantly  chang- 
ing as  regards  the  character  of  the  sounds. 

The  negative  points  are  the  same  as  in  capillary 
bronchitis,  namely,  absence  of  dulness  on  percussion, 
vocal  resonance  and  fremitus  also  being  unaltered. 
Asthma  and  bronchitis  seated  in  small  tubes  agree 
in  the  fact  that  obstruction  is  the  important  physical 
condition.  A  highly  important  differential  point 
relates  to  the  frequency  of  the  respirations;  they 
are  much  increased  in  frequency  in  capillary  bron- 
chitis, and  not  in  asthma.  I  Pathologically  they  differ 
essentially  in  the  fact  that  the  obstruction  is  due  in 
the  latter  affection  to  bronchial  inflammation,  and 
in  the  former  to  spasm.  The  two  affections  differ 
in  the  signs  representing  these  different  conditions, 


164  PHYSICAL    DIAGNOSIS. 

line  moist  bronchial  rales  existing  in  one,  and  loud 
diffused  dry  bronchial  rales  existing  in  the  other. 

Taking  the  difference  as  regards  the  positive 
physical  signs  in  connection  with  the  history  and 
symptoms,  the  differentiation  of  the  two  affections 
may  be  made  without  difficulty. 

The  signs  which  relate  to  the  associated  emphy- 
sematous condition  are  those  which  are  diagnostic 
of  this  condition  existing  irrespective  of  asthma; 
and  the  physical  diagnosis  of  emphysema  will  be 
next  considered.  Coexisting  bronchitis  may  give 
rise  to  moist  bronchial  rfiles  more  or  less  coarse. 
These  are,  however,  often  wanting,  and  they  are 
rarely  marked  during  paroxysms  of  asthma.  When 
present  in  this  pathological  connection,  they  are 
low  in  pitch,  denoting  the  absence  of  solidification 
of  lung. 

Pulmonary  or  Vesicular  Emphysema. 

This  affection,  as  a  rule,  is  seated  exclusively  or 
chiefly  in  the  upper  lobes.  When  it  is  lobar,  in 
contradistinction  from  the  emphysema  existing  in 
comparatively  a  few  disseminated  or  isolated  por- 
tions of  lung,  increase  in  volume  of  the  affected 
lobes  is  an  important  physical  condition  standing  in 
relation  to  certain  signs.  Diminished  range  of  ex- 
pansion with  acts  of  inspiration  is  another  physical 
condition ;  the  affected  lobes  are  in  a  permanent 
state  of  expansion  approximating  to  that  at  the  end 
of  the  inspiratory  act.  It  follows  from  these  condi- 
tions that  the  amount  of  air  is  in  excess  of  the 
normal  proportion  to  the  solids  and  liquids  in  the 
affected  lobes.     Both  lungs  are  affected,  that  is,  the 


PULMONARY   OR   VESICULAR    EMPHYSEMA.      165 

affection  is  bilateral.  In  the  great  majority  of  cases 
chronic  bronchitis  coexists,  and  patients  affected 
with  emphysema  are  often,  but  by  no  means  invari- 
ably, subject  to  paroxysms  of  asthma.  Not  infre- 
quently an  asthmatic  element,  with  or  without  pro- 
nounced paroxysms  of  asthma,  exists  much  of  the 
time  in  connection  with  emphysema.  The  emphy- 
sematous condition,  as  a  rule,  with  few  exceptions, 
is  greater  in  the  upper  lobe  of  the  left  than  of  the 
right  lung.  A  rare  condition,  which  is  generally 
included  under  the  name  emphysema,  differs  mate- 
rially from  the  ordinary  form  of  this  affection.  This 
condition  is  that  also  known  as  senile  atrophy  of  the 
lungs.  The  volume  of  the  lungs  is  not  increased  in 
this  variety  of  emphysema,  the  proportion  of  air 
over  the  solids  is,  however,  in  excess,  owing  to  the 
diminution  of  the  latter  from  atrophy. 

The  diagnostic  evidence  obtained  by  percussion  is 
quite  distinctive  of  lobar  emphysema.  The  reso- 
nance over  the  upper  and  middle  regions  of  the 
chest  on  both  sides  is  vesiculotympanitic,  that  is, 
the  intensity  of  the  resonance  is  abnormally  in- 
creased, the  quality  is  a  combination  of  the  vesicular 
and  tympanitic,  and  the  pitch  is  more  or  less  raised. 
( hving  to  the  fact  that  the  emphysema  is  greater  on 
the  left  than  on  the  right  side,  the  vesiculotympanitic 
resonance  is  more  marked  on  the  left  side.  The 
difference  in  intensity  between  the  two  sides  may 
lead  to  the  error  of  regarding  the  resonance  on  the 
right  side  as  dulness.  The  error  is  avoided  by  at- 
tention to  the  pitch  and  the  quality  of  the  resonance. 
If  dulness  existed  on  the  right  side,  the  pitch  of  the 
sound  should  he  higher  on   that    side:   on  the   other 


106  PHYSICAL    DIAGNOSIS. 

hand,  if  the  difference  in  intensity  be  due  to  the 
greater  amount  of  emphysema  on  the  left  side,  the 
pitch  is  higher  on  that  side,  and  the  quality  vesiculo- 
tympanitic. The  attention  of  the  student  is  particu- 
larly called  to  the  foregoing  points  of  distinction. 
Assuming  that  a  vesiculotympanitic  resonance 
exists  anteriorly  on  both  sides,  and  that  it  is  marked 
on  the  left  as  contrasted  with  the  right  side,  how  is 
the  existence  of  this  sign  on  the  right  side  to  be  de- 
termined ?  The  answer  is,  the  resonance  over  the 
upper  is  to  be  compared  with  that  over  the  lower 
lobe  of  the  right  lung.  Percussing  first  over  the 
upper  lobe  of  the  right  lung,  and  second  over  the 
lower  lobe  of  this  lung,  that  is,  posteriorly,  below 
the  scapula,  or  in  the  infra-axillary  region,  the 
vesiculotympanitic  resonance  over  the  upper  lobe  is 
rendered  manifest.  In  a  series  of  patients  affected 
with  emphysema,  the  uniformity  of  the  results  of 
percussion  is  very  striking;  anteriorly,  over  the  left 
side,  the  resonance  is  vesiculotympanitic  as  com- 
pared with  the  resonance  on  the  right  side,  and  the 
resonance  is  shown  to  be  vesiculo-tympanitic  on  the 
right  side  anteriorly  as  compared  with  the  resonance 
posteriorly  below  the  scapula. 

As  regards  the  abnormal  modifications  of  the 
respiratory  murmur  in  emphysema,  there  is,  Jirst, 
either  weakened  respiratory  murmur  without  notable 
change  in  pitch  or  qualit}7,  or  suppression  of  the 
murmur.  Diminished  intensity  of  the  murmur 
exists  over  the  upper  lobes  on  both  sides,  as  com- 
pared with  the  murmur  over  the  lower  lobes;  and 
in  most  cases  the  greater  diminution  or  the  suppres- 
sion is  on  the  left  rather  than   on  the  right  side. 


PULMONARY  OR   VESICULAR    EMPHYSEMA.       167 

Exceptions  to  the  latter  statement  may  be  caused  by 
obstruction  of  the  bronchial  tubes  on  the  right,  and 
not  on  the  left  side,  by  an  accumulation  of  mucus, 
and,  in  rare  instances,  by  the  fact  that  the  emphy- 
sema is  greater  on  the  right  side.  Occasionally 
there  is  almost  suppression  below  with  preserved 
respiration  above  of  the  emphysematous  type,  and 
this  so  continuous  as  not  to  be  explained  by  obstruc- 
tion of  tubes.  Second,  modifications  in  rhythm  are 
not  infrequent.  These  consist  in  a  shortened  (de- 
ferred) inspiratory,  and  a  prolonged  expiratory 
sound.  In  some  instances  an  inspiratory  sound  is 
wanting,  and  an  expiratory  sound  is  alone  heard. 
Tho  prolonged  expiratory  sound  in  emphysema  is 
always  low  in  pitch  and  blowing  or  non-tubular  in 
quality,  in  these  respects  differing  from  the  prolonged 
expiration  which  denotes  solidification  of  lung,  the 
latter  being  high  in  pitch  and  tubular  in  quality. 
These  essential  points  of  difference  I  claim  to  have 
been  the  first  to  have  distinctly  stated. 

The  foregoing  signs  obtained  by  percussion  and 
auscultation  are  those  which  are,  in  a  positive  sense, 
diagnostic  of  emphysema.  Associated  with  these 
are  certain  important  negative  points,  as  follows: 
vocal  resonance,  vocal  fremitus,  and  bronchial  whis- 
per are  not  notably  altered.  These  negative  points 
suffice  to  exclude  other  affections  than  emphysema. 

Signs  obtained  by  inspection  are  quite  distinctive 
of  this  affection.  Emphysema,  existing  in  a  marked 
degree,  causes  a  characteristic  deformity  of  the  chest : 
the  anterior  surface  is  bulging,  giving  to  the  chest 
an  abnormally  rounded,  bow-windowed,  or  barrel- 
shaped  appearance,  the  lower  part   appearing  t<>  be 


168  PHYSICAL    DIAGNOSIS. 

contracted.  This  deformity  occurs  when  the  em- 
physema has  been  developed  in  early  life.  The 
movements  of  the  chest  in  inspiration  are  character- 
istic. In  tranquil  breathing  there  is  but  little  move- 
ment of  the  upper  and  anterior  regions,  but  in  forced 
breathing  the  sternum  and  ribs  move  together  as  if 
they  were  one  solid  piece.  The  lower  portion  of  the 
chest  and  the  epigastrium  are  retracted  in  inspira- 
tion ;!  the  costal  angle  is  diminished,  the  ribs  and 
cartilages  connected  with  the  sternum  being  some- 
times on  a  line ;  the  soft  parts  above  the  clavicle  and 
sternum  are  often  notably  depressed  with  inspiration. 
Owing  to  depression  of  the  heart  downward  and  in- 
ward, the  cardiac  impulses  are  seen  and  felt  in  the 
epigastrium.  Percussion  and  vocal  resonance  show 
the  superficial  cardiac  region  to  be  diminished  or 
lost,  the  upper  lobe  of  the  left  lung  covering  this 
space.  There  may  be  more  or  less  anterior  curva- 
ture of  the  spine,  and  the  lower  portions  of  the 
scapulas  may  project,  so  that  sometimes  the  plane  of 
these  bones  is  almost  horizontal.  These  striking 
appearances  characterize  cases  in  which  emphysema 
exists  in  a  marked  degree,  and  especially  when  the 
affection  dates  from  early  life.  They  are  less  marked 
or  wanting  if  the  emphysema  be  moderate  in  de- 
gree, and  it  have  taken  place  in  middle-aged  per- 
sons or  those  advanced  in  years. 

In  the  variety  of  emphysema  distinguished  as 
senile,  or  senile  atrophy  of  the  lungs,  in  which  there 
is  coalescence  of  air-vesicles  from  destruction  of  the 

1  The  retraction  may  be  only  apparent.  Professor  Janeway 
states  that  he  has  made  measurements  showing  in  some  cases  that 
there  is  no  real  retraction. 


PLEURISY,  ACUTE    AND    CHRONIC.  169 

cell-walls  without  increased  volume  of  the  affected 
lobes,  the  diagnosis  is  to  be  based  on  the  vesiculo- 
tympanitic resonance  on  percussion,  weakened 
respiratory  murmur,  with,  perhaps,  the  alterations 
in  rhythm,  sinking  of  the  soft  parts  above  the  clavi- 
cles, and  the  negative  points,  exclusive  of  deformity 
of  the  chest,  which  have  been  described. 

Emphysema  can  hardly  be  confounded  with  any 
other  affection  than  phthisis.  The  differentiation 
between  these  two  affections  is  sufficiently  easy  if 
the  diagnostic  points,  positive  and  negative,  of  the 
former,  be  appreciated.  Phthisis  occurring  in  a 
patient  affected  with  emphysema  makes  a  somewhat 
difficult  problem  in  diagnosis;  but,  fortunately  for 
the  diagnostician,  a  patient  with  emphysema  very 
rarefy  becomes  phthisical. 

Owing  to  the  frequency  with  which  an  asthmatic 
element  enters  into  the  clinical  history  of  emphy- 
sema, the  dry  bronchial  (sibilant  and  sonorous)  rales 
are  often  present,  even  when  paroxysms  of  asthma 
do  not  occur. 

Pleurisy,  Acute  and  Chronic — Empyema — Hydrothorax. 

In  the  first  stage  of  acute  pleurisy — that  is,  prior 
to  the  effusion  of  liquid — the  physical  conditions 
are,  the  presence  of  more  or  less  recently  exuded, 
soft  lymph  upon  the  pleural  surfaces,  which  are  now 
in  contact,  and  restrained  movements  of  respiration 
mi  the  affected  side  in  consequence  of  the  pain  which 
they  occasion.  In  the  second  stage,  serous  liquid 
accumulates  within  the  pleural  cavity,  the  quantity 
varying  in  different  cases,  sometimes,  although 
rarely,   filling  the  chesl   on   the  affected  side.     In 

16 


170  PHYSICAL    DIAGNOSIS. 

proportion  to  the  quantity  of  liquid  the  space  over 
which  the  pleural  surfaces  are  in  coutactis  restricted, 
the  movements  of  these  surfaces  over  each  other  are 
limited,  and  the  lung  is  condensed.  In  the  third 
stage  the  quantity  of  liquid  decreases,  the  space 
over  which  the  pleural  surfaces  are  in  contact  in- 
creases, and  the  compressed  lung  is  more  or  less 
expanded.  The  lymph  upon  the  pleural  surfaces 
becomes  more  dense  and  adherent.  The  surfaces 
may  become  agglutinated  by  the  intervening  lymph. 
Finally,  in  convalescence,  permanent  adhesions  re- 
sult from  the  production  or  growth  of  areolar  tissue. 

In  subacute  and  chronic  pleurisy  there  is  the  same 
series  of  physical  conditions,  the  points  of  difference 
being,  as  a  rule,  a  less  amount  of  exudation,  and  a 
greater  amount  of  effused  liquid.  The  quantity  of 
liquid  in  chronic  pleurisy  is  often  sufficient  to  com- 
press the  lung  into  a  small  solid  mass  situated  at 
the  upper  and  posterior  part  of  the  chest,  and  to 
dilate  the  affected  side.  The  heart  is  often  removed 
from  its  normal  situation.  If  the  pleurisy  be  on  the 
left  side,  the  heart  may  be  pushed  laterally  beyond 
the  right  margin  of  the  sternum;  if  the  pleurisy  be 
on  the  right  side,  the  heart  is  pushed  laterally  to  the 
left  of  its  normal  situation. 

In  empyema  the  accumulation  of  pus  is  apt  to  be 
still  greater  than  that  of  serous  effusion  in  simple 
chronic  pleurisy,  causing,  of  course,  greater  dilata- 
tion of  the  chest,  and  more  displacement  of  the 
heart. 

In  these  varieties  of  pleurisy  the  affection,  with 
rare  exceptions,  is  unilateral. 

In  hydrothorax  the  conditions  differ,  first,  as  re- 


PLEURISY,  ACUTE    AND    CHRONIC.  171 

gards  the  absence  of  the  exudation  of  lymph;  second, 
the  affection  is  bilateral,  the  effusion  of  liquid  taking 
place  in  both  pleural  cavities;  and,  third,  although 
the  quantity  of  liquid  may  be  considerably  greater 
on  one  side,  the  accumulation  very  rarely,  if  ever,  is 
sufficient  to  cause  much  dilatation  of  the  chest  on 
that  side,  with  complete  condensation  of  the  lung, 
and  notable  displacement  of  the  heart. 

The  signs  in  the  first  stage  of  acute  pleurisy  are 
relative  feebleness  of  the  respiratory  murmur  on  the 
affected  side,  from  the  restrained  respiratory  move- 
ments on  that  side,  and  a  rubbing  friction-sound. 
The  former  is  not  distinctive  of  pleurisy,  being 
present  when  the  respiratory  movements  on  one  side 
are  restrained  by  pain  in  intercostal  neuralgia  and 
pleurodynia.  A  friction-sound  is  not  always  ob- 
tained. In  the  absence  of  this  sound  the  physical 
diagnosis  cannot  be  made  with  positiveness  prior  to 
the  effusion  of  liquid.  Assuming  that  the  general 
and  local  symptoms  point  to  an  acute  inflammatory 
affection,  the  differential  diagnosis  relates  to  pleurisy 
and  pneumonia.  A  pleural  friction-sound  may  be 
present  in  the  latter  as  well  as  the  former  of  these 
two  affections.  The  pathognomonic  sign  of  pneu- 
monia, the  crepitant  rale,  being  wanting,  the  differ- 
entiation, in  this  stage,  must  rest  on  diagnostic 
points  pertaining  to  the  symptoms.1 

In  the  second  stage  of  acute  pleurisy  the  diag- 
nostic signs  are  those  which  denote  the  presence  of 

1  Professor  Jane  way  stales  thai  he  has  sometimes  beard  a  crepi- 
tant rale  ut  the  inception  of  pleurisy,  without  coexisting  pneu- 
monia. The  mechanism  in  these  instances  is  the  Bame  as  in 
pneumonia. 


172  PHYSICAL    DIAGNOSIS. 

liquid  within  the  pleural  cavity.  These  signs  are 
simple  and  distinctive.  There  is  either  dulness  or 
flatness  on  percussion  at  the  base  of  the  chest,  ex- 
tending upward  a  distance  proportionate  to  the 
quantity  of  liquid.  If  the  trunk  be  in  a  vertical 
position — that  is,  the  patient  sitting  or  standing — 
the  line  of  demarcation  between  the  dulness  or  flat- 
ness and  pulmonary  resonance  is,  or  approximates 
to,  a  horizontal  line  on  the  anterior  aspect  of  the 
chest.  This  line  denotes  the  level  of  the  liquid,  and 
is  easily  obtained  by  percussion.  It  is  as  easily  de- 
termined by  auscultating  the  vocal  resonance,  this 
either  abruptly  ceasing  or  being  notably  diminished 
at  the  level  of  the  liquid.  Having  ascertained  the 
line  forming  the  upper  boundary  of  dulness  or  flat- 
ness on  the  anterior  aspect  of  the  chest,  the  patient 
sitting  or  standing,  if  the  position  be  changed  to 
recumbency  on  the  back,  and  the  pulmonary  reso- 
nance be  found  then  to  extend  more  or  less  below 
this  line,  this  fact  is  demonstrative  proof  of  the  pres- 
ence of  liquid.  Proof  in  this  way  is  obtained  in  a 
large  majority  of  cases,  the  exceptional  cases  being 
those  in  which  the  pleural  surfaces  are  united,  either 
by  agglutination  or  permanent  adhesions,  above  the 
level  of  the  liquid.1  The  resonance  on  percussion 
over  the  lung  above  the  level  of  the  liquid  is  gener- 

1  The  statement  with  regard  to  a  horizontal  line  denoting  the 
level  of  the  liquid  does  not  apply  to  the  posterior  aspect  of  the 
chest.  Observations  show  that  posteriorly  the  lung  extends  more 
or  less  downward  near  the  spinal  column,  and  that  the  level  of  the 
liquid  forms  a  curve  whieh  may  he  represented  by  the  letter  S. 
Vide  article  by  Professor  G.  M.  Garland,  in  the  New  York  Medical 
Journal,  number  for  November,  1879.  Also  treatise  on  "  Pneumo- 
Dy mimics,"  by  Professor  Garland,  1878. 


PLEUKISY,  ACUTE    AND    CHRONIC  173 

ally  vesiculotympanitic — the  intensity  increased,  the 
pitch  raised,  the  vesicular  and  the  tympanitic  quality 
combined.  Sometimes  there  is  so  little  vesicular 
quality  in  this  vesiculotympanitic  resonance,  that  it 
may  seem  to  be  purely  tympanitic,  and  is  suggestive 
of  pneumothorax.  Associated  signs  will  always 
prevent  this  error  of  observation.  As  a  rule,  vocal 
resonance  and  fremitus  are  either  notably  lessened 
or  suppressed  over  the  portion  of  the  chest  situated 
below  the  level  of  the  liquid.  There  are  occasional 
exceptions  to  this  rule.  The  respiratory  sound  below 
the  level  of  the  liquid  is  suppressed.  If  any  be  heard, 
it  is  transmitted  either  from  the  lung  above  the 
liquid,  or  laterally,  from  the  lung  on  the  other  side 
of  the  chest.  Above  the  liquid  the  respiratory 
sound,  as  a  rule,  is  weakened.  If  the  amount  of 
liquid  be  sufficient  to  produce  much  condensation 
of  lung,  the  respiratory  sound  is  broncho-vesicular. 
Sometimes,  owing  to  the  pleural  surfaces  above 
being  adherent,  a  strip  of  lung  at  the  level  of  the 
liquid  is  sufficiently  condensed  by  compression  to 
give  a  bronchial  respiration.  Under  these  circum- 
stances, there  will  be  either  bronchophony  or  the 
modification  of  that  sign  known  as  asgophony.  If 
the  lung  be  not  sufficiently  compressed  for  the  pro- 
duction of  these  signs  of  solidification,  the  vocal 
resonance  is  simply  more  or  less  increased.  The 
fremitus  is  usually  increased  above  the  liquid.  Over 
the  unaffected  side  the  respiratory  murmur  is  in- 
creased in  intensity. 

The  foregoing  signs  are  present  when  the  pleural 
cavity  i^  partially  filled;  a  quarter,  a  hall,  or  two- 
thirds  of  the  thoracic  space  being  occupied  by  liquid. 

16* 


174  PHYSICAL    DIAGNOSIS. 

The  signs  present  when  the  cavity  is  completely 
filled  will  be  presently  stated  in  connection  with 
chronic  pleurisy. 

The  signs  which  have  been  stated  show  not  only 
the  presence  of  liquid  but  its  quantity.  By  means 
of  these  signs  are  readily  ascertained  the  progressive 
increase  or  decrease  in  the  quantity  of  liquid,  and 
its  disappearance.  After  the  liquid  has  disappeared, 
often  notable  dulness  on  percussion  remains  for  some 
time,  showing  the  presence  of  lymph  not  yet  ab- 
sorbed. During  the  decrease  of  the  liquid,  and  after 
its  disappearance,  a  friction-murmur  is  often  per- 
ceived. This  murmur  is  now  apt  to  be  rough — a 
rasping,  grating,  or  creaking  sound.  It  may  be  loud 
enough  to  be  heard  by  the  patient,  and  by  others  at 
a  distance  from  the  chest.  It  continues  sometimes 
for  a  considerable  period. 

The  physical  diagnosis  in  cases  of  chronic  pleurisy, 
when  the  liquid  occupies  a  portion  only  of  the  tho- 
racic space,  rests,  of  course,  on  precisely  the  same 
signs  as  in  cases  of  acute  pleurisy.  If,  however,  the 
chest  on  the  affected  side  be  filled  and  dilated,  cer- 
tain of  the  signs  which  have  been  stated  are  want- 
ing, and  others  are  added.  The  affected  side  is 
everywhere  flat  on  percussion.  Flatness  on  percus- 
sion over  the  whole  of  one  side,  the  affection  being 
chronic,  denotes,  as  a  rule,  with  rare  exceptions, 
either  chronic  simple  pleurisy  or  empyema.  Respira- 
tory sound  is  wanting  except  at  the  summit  over  or 
near  the  compressed  lung,  where  it  is  bronchial. 
Some  cases  offer  an  important  exception  to  this  rule, 
namely,  the  bronchial  respiration  is  diffused  over 
the  greater  part,  or  even  the  whole,  of  the  affected 


PLEURISY,  ACUTE    AND    CHRONIC.  175 

side.  The  student  should  bear  in  mind  this  fact; 
otherwise  the  diffusion  of  the  bronchial  respiration 
may  lead  to  the  suspicion  that  the  flatness  on  per- 
cussion denotes  solidification  of  lung  and  not  the 
presence  of  liquid.  Other  signs,  however,  should 
always  correct  this  error.  Vocal  resonance  and 
fremitus  are,  with  some  exceptions,  either  suppressed 
or  notably  diminished  over  the  whole  of  the  affected 
side.  Generally,  even  when  the  chest  is  not  dilated, 
the  intercostal  depressions  are  lessened  or  abolished. 
If  the  walls  of  the  chest  be  thinly  covered  with  in- 
tegument, the  two  sides  present  a  marked  contrast 
in  this  respect.  This  is  seen  especially  at  the  middle 
and  lower  regions  of  the  chest  anteriorly  and  later- 
ally.  It  is  especially  marked  at  the  end  of  the  in- 
spiratory act.  If  the  affected  side  be  dilated,  this 
is  apparent  on  inspection,  and  maybe  determined 
accurately  by  semicircular  or  diametric  mensuration, 
calipers  being  required  for  the  latter.  The  respira- 
tory movements  on  the  affected  side  are  diminished 
or  annulled,  and  they  are  increased  on  the  healthy 
side,  the  two  sides  affording  a  marked  contrast  in 
this  regard.  If  the  pleurisy  be  on  the  left  side,  the 
impulses  of  the  heart  are  not  infrequently  felt  on 
the  right  of  the  sternum.  If  the  impulses  cannot 
be  felt,  auscultation  shows  the  maximum  of  the  in- 
tensity of  the  heart-sounds  to  be  more  or  less  removed 
to  the  right.  If  the  pleurisy  be  on  the  right  side, 
the  impulses  or  sounds  of  the  heart  denote  more  or 
less  displacement  laterally  to  the  left.  The  intensity 
of  the  respiratory  murmur  on  the  unaffected  side  is 
notably  increased. 

In  eases  of  empyema   the  same   si-ns   are   present 


17G  PHYSICAL    DIAGNOSIS. 

as  in  chronic  pleurisy.  The  character  of  the  liquid 
does  not  alter  appreciably  any  of  the  signs  which 
have  been  stated.  Dilatation  of  the  affected  side  of 
the  chest  is  more  apt  to  occur,  and  to  be  more 
marked  than  in  simple  pleurisy.  The  differential 
diagnosis  between  these  two  varieties  of  pleurisy  is 
to  be  made  with  positiveness  by  the  introduction  of 
the  needle  of  a  hypodermic  syringe  having  good 
suction  force,  previously  cleaned  and  carbolized, 
and  obtaining  enough  of  the  liquid  to  ascertain  its 
character. 

When  the  left  pleural  cavity  is  filled  with  pus,  the 
movements  of  the  heart  sometimes  give  to  the 
affected  side  of  the  chest  an  impulse  perceived  by 
the  eye  and  touch;  hence  the  term,  pulsating  em- 
pyema. After  a  spontaneous  perforation  of  the 
chest,  followed  by  a  circumscribed  purulent  collec- 
tion beneath  the  integument,  communicating  with 
the  pus  within  the  pleural  cavity,  the  tumor  thus 
formed  sometimes  has  a  strong  pulsation  which  is 
synchronous  with  the  ventricular  systole,  and  may 
give  rise  to  the  suspicion  of  aneurism. 

In  cases  of  hydrothorax,  the  signs  denote  partial 
filling  of  the  chest  on  both  sides.  The  affection  is 
bilateral.  Generally  the  quantity  of  liquid  in  the 
two  sides  is  not  equal,  and  there  is  often  a  notable 
disparity  in  this  respect.  Friction-sounds  are  never 
present.  Variation  of  the  level  of  the  liquid  with 
change  of  the  position  of  the  patient  from  the  ver- 
tical to  the  horizontal,  is  nearly  always  determinable. 
Hydrothorax,  meaning  by  this  term  a  purely  dropsi- 
cal affection,  is  to  be  differentiated  from  double 
pleurisy  with  effusion.     The  history  and  symptoms, 


PNEUMOTHORAX.  177 

taken  in  connection  with  the  signs,  suffice  for  this 
discrimination. 

Pneumothorax — Pneumo-hydrothorax — Pneumo- 
pyothorax. 

In  the  extremely  rare  cases  of  pneumothorax,  that: 
is,  as  distinguished  from  pneumo-hydrothorax  and 
pneumo-pyothorax,  the  physical  conditions  are:  the 
presence  of  air  partially  or  completely  occupying  the 
thoracic  space,  and  condensation  of  lung  in  propor- 
tion to  the  space  occupied  by  air. 

The  diagnostic  signs  are,  a  purely  tympanitic 
resonance  over  a  portion  or  the  whole  of  the  affected 
side  of  the  chest :  suppression  of  the  vesicular  mur- 
mur over  a  space  corresponding  to  that  in  which 
tympanitic  resonance  is  obtained,  with  notable  dim- 
inution or  suppression  of  vocal  resonance  and  fre- 
mitus. Over  the  compressed  lung,  if  the  condensation 
amount  to  complete  or  considerable  solidification, 
there  will  be  bronchial  respiration  and  bronchophony; 
if  the  solidification  be  neither  complete  nor  consider- 
able, there  will  be  broncho-vesicular  respiration  with 
increased  vocal  resonance  and  fremitus.  The  accu- 
mulation of  air  may  be  sufficient  to  dilate  the  affected 
side,  and  to  restrain  or  annul  the  respiratory  move- 
ments- on  this  side.  The  appearances  on  inspection 
are  then  precisely  the  same  as  in  the  cases  of  chronic 
pleurisy  and  empyema  in  which  the  affected  side  is 
dilated  from  the  presence  of  liquid.  Pneumothorax 
is,  however,  at  once  differentiated  by  the  tympanitic 
resonance  on  percussion.  It  one  side  of  the  chest  be 
more  or  less  dilated,  and  the  resonance  over  the  side 
be   purely   tympanitic,   the   thoracic   space   must    be 


178  PHYSICAL    DIAGNOSIS. 

filled,  not  with  liquid  but  with  air.  The  intensity 
of  the  respiratory  murmur  on  the  healthy  side  is 
increased. 

In  the  great  majority  of  cases  in  which  the  pleural 
cavity  contains  air,  there  is  also  present  more  or  less 
liquid,  which  may  be  serous  or  purulent.  The  affec- 
tion is  then  known  as  pneumo-hydrothorax  if  the 
liquid  be  serous,  and  pneumo-pyothorax  if  it  be 
purulent.  The  physical  conditions  are  the  same  as 
in  pneumothorax,  with  the  addition  of  the  presence 
of  liquid.  The  relative  proportions  of  liquid  and  air 
in  different  cases  are  variable,  and,  also,  in  the  same 
case  at  different  periods. 

The  physical  diagnosis  of  pneumo-hydrothorax 
and  of  pneumo-pyothorax,  as  distinguished  from 
pneumothorax,  embraces  the  signs  of  liquid,  in  addi- 
tion to  those  of  air,  within  the  pleural  cavity.  If 
the  quantity  of  liquid  be  large  or  considerable,  per- 
cussion at  the  base  of  the  chest  gives  flatness  extend- 
ing upward  more  or  less,  and  tympanitic  resonance 
above,  the  patient  either  sitting  or  standing.  A 
change  from  the  vertical  to  the  horizontal  position 
invariably  causes  variation  of  the  upper  limit  of  the 
flatness,  inasmuch  as  the  liquid  and  air  change  their 
relative  situations  without  an  exception.  The  quan- 
tity of  liquid  is  determined  approximatively  by  ascer- 
taining the  space  over  which  the  flatness  on  percus- 
sion extends.  The  line  which  divides  the  flatness 
and  the  tympanitic  resonance  does  not  accurately 
denote  the  level  of  the  liquid,  because  tympanitic 
resonance  is  transmitted  a  certain  distance  below 
this  level,  hence  it  is  always  to  be  assumed  that  the 


ACUTE    LOBAR    PNEUMONIA.  179 

level  of  the  liquid  is  somewhat  higher  than  the  upper 
boundary  of  the  flatness. 

In  either  pneumothorax,  pneumo-hydrothorax,  or 
pneumo-pyothorax  a  group  of  auscultatory  signs  is 
often  found  which  are  highly  diagnostic,  indeed 
almost  pathognomonic.  These  signs  are  amphoric 
respiration,  amphoric  voice  or  echo,  and  metallic 
tinkling.  The  amphoric  and  the  tinkling  sound- 
may  be  present,  either  without  the  other,  but  they 
are  not  infrequently  associated.  Neither  are  present 
in  every  case,  and  they  are  not  present  in  the  same 
case  at  all  times;  their  absence,  therefore,  by  no 
means  excludes  the  affections,  and  they  are  not 
essential  to  the  diagnosis.  When  present  they  de- 
note either  air  or  air  and  liquid  in  the  pleural  cavity 
with  perforation  of  lung  or  a  large  phthisical  cavity. 
Their  occurrence  in  the  latter  is  comparatively  rare, 
and  whenever  they  are  associated  with  other  signs 
already  stated,  their  diagnostic  import  is  demonstra- 
tive. 

I'neumo-hydrothorax  or  pneumo-pyothorax  may 
almost  invariably  be  diagnosticated  instantly  by  the 
presence  of  a  succussion  sound.  Whenever  distinct 
splashing  is  produced  by  succussion  and  referable  to 
the  chest,  that  is,  not  produced  within  the  stomach, 
it  is  demonstrative  of  the  presence  of  air  and  liquid 
within  the  pleural  cavity. 

Acute  Lobar  Pneumonia. 

In  the  first  stage  of  this  disease  there  is  an  abnor- 
mal accumulation  of  blood  within  the  vessels  of  the 
affected  lobe  (active  congestion  or  hyperemia),  with 
Borne  exudation  within  the  air-vesiclee  and  bronchi- 


180  PHYSICAL    DIAGNOSIS. 

oles.  Generally  there  is  some  exuded  lymph  upon 
the  pleural  surface,  this  being  due  to  circumscribed 
dry  pleurisy.  In  most  cases  there  is  also  circum- 
scribed bronchitis,  which  is  limited  to  the  tubes 
within  the  affected  lobe.  In  the  second  stage  there 
is  solidification  due  to  the  increase  of  exudation 
within  the  air-vesicles.  The  solidification,  at  first 
limited,  extends  either  rapidly  or  slowly,  as  a  rule, 
over  the  whole  lobe.  Exceptionally  more  or  less 
liquid  effusion  into  the  pleural  cavity  takes  place 
(pleuro-pneumonia),  the  pleurisy  then  extending  be- 
yond the  limits  of  the  affected  lobe.  In  this  stage 
the  pneumonia  ma}7  involve  either  another  lobe  of 
the  lung  primarily  affected,  or  a  lobe  of  the  opposite 
lung,  and  sometimes  the  disease,  by  successive  inva- 
sions, extends  over  the  whole  of  one  lung,  together 
with  a  lobe  of  the  opposite  lung.  The  pneumonia, 
in  these  secondary  invasions,  is  usually  accompanied 
by  pleurisy  and  bronchitis.  In  the  stage  of  resolu- 
tion the  solidification  of  the  affected  lobe  or  lobes 
decreases,  sometimes  rapidly  and  sometimes  slowly, 
until  the  normal  condition  is  restored.  If  resolution 
do  not  take  place,  and  the  disease  pass  into  the  stage 
of  purulent  infiltration,  the  air-vesicles  and  bronchial 
tubes  contain  a  puruloid  liquid  in  greater  or  less 
quantity.  Exceptionally  pus  is  collected  in  a  cavity, 
or  in  cavities,  constituting  pulmonary  abscess. 

The  physical  diagnosis  of  acute  lobar  pneumonia 
in  the  first  stage  must  be  based  on  the  presence  of 
the  crepitant  rale,  with  moderate  or  slight  dulness 
on  percussion  over  the  affected  lobe.  There  is  some- 
times in  this  stage  a  pleuritic  rubbing  sound  over 
the  affected  lobe.     The  crepitant  rale  is  not  always 


ACUTE    LOBAR    PNEUMONIA.  181 

present,  and  hence  the  affection  cannot  be  excluded 
by  the  absence  of  this  sign.  When  present,  taken 
in  connection  with  the  symptoms,  this  sign  is  pathog- 
nomonic of  the'disease.  It  is  important  not  to  mis- 
take for  this  sign  fine  bubbling  or  the  subcrepitant 
rule.  When  the  crepitant  rale  is  wanting,  a  positive 
physical  diagnosis  must  be  deferred  until  more  or 
less  of  the  affected  lobe  becomes  solidified,  that  is, 
when  the  disease  passes  into  the  second  stage. 

The  diagnosis  in  the  second  stage  is  to  be  based 
on  the  signs  of  solidification  furnished  by  ausculta- 
tion and  percussion.  The  auscultatory  signs  are  the 
broncho-vesicular,  followed  by  the  bronchial  respi- 
ration ;  increased  vocal  resonance,  followed  by  bron- 
chophony, and  increased  bronchial  whisper,  followed 
by  whispering  bronchophony.  The  signs  of  solidi- 
fication -are  manifest  at  first  within  a  circumscribed 
space,  situated  over  either  the  upper,  the  lower,  or 
the  middle  portion  of  the  affected  lobe,  and  either 
rapidly  or  slowly  the  signs  extend  in  most  cases 
over  the  entire  lobe.  The  crepitant  rale,  if  it  have 
been  present  in  the  first,  generally  disappears  in  the 
second  stage.  Sometimes,  however,  it  is  not  en- 
tirely lost  in  this  stage.  The  broncho-vesicular 
respiration,  increased  vocal  resonance,  and  increased 
bronchial  whisper  are  present  when  the  solidifica- 
tion is  slight  or  moderate;  the  bronchial  respira- 
tion, bronchophony,  and  bronchophonic  whisper 
take  their  place  when  the  solidification  becomes 
considerable  or  complete.  The  latter  signs,  as  a 
rule,  speedily  follow,  inasmuch  as  the  solidification 
in  iin i-t  cases  quickly  becomes  complete  or  con- 
siderable.     The   foregoing    three    signs,   denoting 

16 


182  PHYSICAL    DIAGNOSIS. 

considerable  or  complete  solidification,  are  usually 
present.  Bronchial  respiration,  however,  is  some- 
times present  without  bronchophony,  and  vice  versa. 
Either,  present  alone,  suffices  to  show  the  existence 
and  the  extent  of  the  solidification.  Moist  bron- 
chial or  bubbling  rales  are  sometimes,  but  rarely, 
heard  over  the  affected  lobe. 

There  is  notable  dulness  on  percussion  in  the 
second  stage.  The  dulness  may  approximate  and 
even  amount  to  flatness.  If  a  single  lobe  be  af- 
fected, the  dulness  or  flatness  extends  over  a  space 
corresponding  to  that  occupied  by  the  lobe  or  the 
portion  of  it  which  is  solidified.  In  the  antero- 
lateral aspects  of  the  chest,  the  dividing  line  be- 
tween the  solidified  and  the  healthy  lobe  is  readily 
ascertained  by  percussion,  and  this  line  is  coincident 
with  the  interlobar  fissure.1  It  sometimes  happens 
that  the  upper  and  the  lower  lobe  of  the  right  lung 
are  affected,  the  middle  lobe  not  becoming  involved. 
The  space  corresponding  to  the  middle  lobe  may 
then  form  an  island  of  resonance  surrounded  by 
notable  dulness  on  percussion. 

Whenever  one  lobe  of  a  lung  is  affected,  the  reso- 
nance over  the  unaffected  part  of  the  same  lung  is 
abnormally  increased,  the  pitch  is  raised,  and  the 
quality  is  vesiculotympanitic;  vesiculo-tympanitic 
resonance,  in  other  words,  is  produced.  This 
renders  more  marked  the  contrast  between  dulness 

1  "With  reference  to  the  localization  of  pneumonia  in  the  upper 
or  lower  lobes  the  situation?  of  the  interlobar  fissures  on  the  an- 
terior, posterior,  and  lateral  aspects  of  the  chest  are  to  be  kept  in 
mind,  vide  Figs.  1  and  2,  pages  30  and  37. 


ACUTE  LOBAR  PNEUMONIA.       183 

over  the  solidified,  and  resonance  over  the  healthy, 
lobe. 

Over  a  portion  of  an  upper  lobe  in  the  second 
stage,  instead  of  notable  d ulness  or  flatness,  there 
may  be  marked  tympanitic  resonance.  This  reso- 
nance proceeds  from  air  within  the  trachea  and  the 
bronchi  exterior  to  the  lungs,  the  lung  substance 
being  completely  solidified ;  it  is  chiefly  or  espe- 
cially marked  over  the  site  of  these  air-tubes.  In 
some  cases  the  tympanitic  resonance  has  either  the 
cracked-metal  or  the  amphoric  intonation.  These 
signs,  per  se,  might  suggest  either  pneumothorax  or 
phthisical  cavities;  the  associated  respiratory  and 
vocal  signs,  however,  show  only  solidification  of 
lung.  In  cases  of  pneumonia  affecting  the  left 
lung,  a  tympanitic  resonance  is  not  infrequently 
propagated  from  the  stomach  more  or  less  upward 
over  the  affected  side  of  the  chest.  This  may  be 
readily  traced  to  the  stomach.  On  the  right  side,  a 
tympanitic  resonance  is  sometimes  propagated  a 
certain  distance  upward  from  the  transverse  colon. 

The  commencement  of  the  stage  of  resolution  is 
denoted  by  a  broncho-vesicular  respiration.  The 
first  change  observed  is  the  presence  of  a  little 
vesicular  quality  in  the  inspiratory  sound.  When 
this  is  observed,  the  respiration  is  no  longer  bron- 
chial, but  has  become  broncho-vesicular,  although 
the  pitch  is  still  high,  and  the  expiration  is  pro- 
longed, high,  tubular.  This  slight  change  shows 
that  air  begins  to  enter  the  pulmonary  vesicles.  As 
resolution  goes  on,  more  and  more  of  the  vesicular 
takes  tin'  place  of  the  tubular  quality  in  the  inspira- 
tory Bound,  and  the  pitch  is  lowered  in  proportion; 


184  PHYSICAL    DIAGNOSIS. 

the  expiratory  sound  becomes  proportionately  less 
and  less  prolonged,  its  pitch  lowered,  its  quality 
less  tubular,  until,  at  length,  the  normal  characters 
of  the  respiratory  murmur  are  regained.  Resolu- 
tion is  then  complete. 

While  the  broncho-vesicular  respiration  is  under- 
going the  modifications  just  stated,  the  vocal  sounds 
have  corresponding  changes.  Bronchophony  per- 
sists for  some  time  after  the  respiration  has  become 
broncho-vesicular,  and  then  disappears,  increased 
vocal  resonance  generally  taking  its  place  and  per- 
sisting until  resolution  is  completed.  The  bronchial 
whisper  loses  its  bronchophonic  characters  and  is 
simply  increased  until  its  normal  characters  are  re- 
gained. While  the  solidification  is  complete,  the 
vocal  fremitus  may,  or  may  not,  be  increased.  It  is 
sometimes  diminished.  When,  however,  resolution 
has  so  far  progressed  that  bronchophony  is  lost,  the 
fremitus  is  usually  greater  than  in  health,  and  so 
continues,  but  progressively  lessening  until  the 
solidification  entirely  disappears. 

During  the  progress  of  resolution,  the  dulness  on 
percussion  diminishes  in  proportion  as  air  enters 
the  air-vesicles.  If  tympanitic  resonance  have  been 
present  over  the  upper  lobe,  this  gives  place  to  a 
vesicular  resonance.  Some  dulness,  however,  re- 
mains after  the  completion  of  resolution,  and 
persists  until  the  exuded  lymph  on  the  pleural 
surface  is  absorbed.  The  amount  of  dulness  re- 
maining when  the  respiratory  and  vocal  signs  de- 
note resolution,  is  proportionate  to  the  quantity  of 
exudation  incident  to  the  associated  pleurisy. 

In  this  stage  the  crepitant  rale  not  infrequently 


ACUTE    LOBAR    PNEUMONIA.  185 

returns,  if  it  have  entirely  disappeared  during  the 
second  stage,  and  if  it  have  persisted,  it  is  more 
marked  and  diffused.  It  is  now  known  as  the  re- 
turning crepitant  rale.  More  frequently  the  rale 
in  this  stage  is  a  fine  bubbling  or  the  so-called  sub- 
crepitant.  Both  rfdes  are  not  infrequently  associ- 
ated, and,  from  the  distinctive  characters  of  each, 
they  are  readily  distinguished.  Moist  rales  more  or 
less  fine  or  coarse  are  not  infrequent.  The  pitch  of 
these  rales  remains  more  or  less  high  until  the  solidi- 
fying exudation'is  completely  absorbed. 

If  the  affection  pass  into  the  stage  of  purulent  in- 
filtration, the  respiratory  sounds  are  feeble  or  sup- 
pressed, having,  if  present,  more  or  less  of  the 
bronchial  characters.  Bubbling  bronchial  rfiles, 
coarse  and  fine,  are  abundant.  Weak  broncho- 
phony may  persist,  or  the  vocal  resonance  may  be 
diminished.  Fremitus  may,  or  may  not,  be  in- 
creased. Xotable  dulness  or  flatness  on  percussion 
remains. 

If  the  pneumonia  result  in  pulmonic  abscess, 
there  will  be  notable  dalness  or  flatness  on  percus- 
sion within  a  circumscribed  space,  together  with 
absence  of  respiratory  murmur,  and  diminished  or 
suppressed  vocal  resonance.  These  signs  warrant 
a  probable  diagnosis  which  is  corroborated  by  the 
sudden  expectoration  of  pus  in  a  considerable  quan- 
tity. The  signs  just  stated  may  then  be  followed 
by  those  denoting  a  cavity,  namely,  cavernous  respi- 
ration and  whisper,  with  intense  vocal  resonance. 


10* 


186  PHYSICAL    DIAGNOSIS. 

Circumscribed  Pneumonia — Embolic  Pneumonia—  Hemor- 
rhagic Infarctus  or  Pulmonary  Apoplexy. 

The  form  of  pneumonia  known  as  lobular  pneu- 
monia, occurring  chiefly  in  children,  has  been  con- 
sidered (vide  Bronchitis  seated  in  small-sized  tubes). 
Whenever  circumscribed,  as  a  rule,  pneumonia  is 
secondary  to  some  other  pulmonary  affection.  Cir- 
cumscribed pneumonia,  giving  rise  to  an  intra- 
vesicular  exudation  which  may  disappear  readily  by 
resolution  or  absorption,  is  not  very  infrequent  in 
cases  of  phthisis.  The  signs  are  those  which  repre- 
sent solidification  of  lung  within  an  area  more  or 
less  circumscribed ;  but  the  differentiation  from  the 
solidification  proper  to  phthisis  can  only  be  made 
with  positiveness  after  the  signs  have  shown  that 
the  solidification  has  notably  diminished  or  disap- 
peared. 

In  embolic  pneumonia  there  may  be  dulness  on 
percussion,  with  feeble  bronchial  or  broncho-vesicu- 
lar respiration,  or  suppression  of  respiratory  sound, 
wreak  bronchophony  or  increase  of  vocal  resonance, 
within  a  circumscribed  space,  or  within  spaces, 
generally  on  the  posperior  aspect  of  the  chest,  and 
oftenest  on  the  right  side.  These  signs,  taken  in 
connection  with  the  symptoms  and  pathological  con- 
ditions which  are  consistent  with  the  supposition  of 
emboli  received  into  the  right  side  of  the  heart, 
namely,  when  the  pulmonary  symptoms  follow  puer- 
peral disease,  ulcers,  wounds,  injuries,  or  venous 
thrombosis,  render  the  diagnosis  quite  positive.  If, 
however,  the  pulmonary  affection  consist  of  small 
disseminated  nodules,  the  foregoing  signs  will  not 


PULMONARY  GANGRENE.         187 

be  present.  The  diagnosis  then  must  be  based  on 
the  history  and  symptoms,  taken  in  connection  with 
the  exclusion  of  other  pulmonary  affections  by  the 
absence  of  signs  which  should  be  present  if  they  ex- 
isted. Bubbling  rales,  the  pitch  more  or  less  raised, 
at  different  situations  may  indicate  the  probable 
sites  of  the  nodules.  There  may  be  pleuritic  friction- 
sounds.  The  signs  may  show,  as  a  complication, 
pleurisy  with  effusion. 

Extravasation  of  blood  (pneumorrhagia),  if  it  be 
in  small  spaces,  gives  rise  to  no  definite  physical 
signs.  If,  however,  extravasation  extend  over  a 
considerable  space,  there  will  be  dulness  on  percus- 
sion, with  feeble  or  suppressed  respiratory  sound 
within  an  area  corresponding  to  the  extent  of  the 
extravasation.  Within,  and  near  this  area,  there 
will  be  likely  to  be  moist  bronchial  rales  more  or 
less  tine  or  coarse. 

Pulmonary  Gangrene. 

In  diffused  pulmonary  gangrene  the  physical  signs 
are  those  of  solidification  extending  over  the  greater 
part  or  the  whole  of  a  lobe.  The  diagnosis,  how- 
ever, can  only  be  made  when,  in  connection  with 
these  signs,  there  are  present  the  characteristic  fetor 
of  the  breath  and  expectoration. 

In  circumscribed  gangrene  there  is  dulness  or  flat- 
ness on  percussion  within  an  area  corresponding  to 
the  extent  of  the  affection,  with  either  suppression 
of  respiratory  sound  or  bronchial  respiration,  and 
the  vocal  signs  of  solidification.  Within  and  Dear 
this  Bpace  moisl  bronchial  raies,  more  or  less  raised 
in    pitch,  arc    likely   to   I"'   heard.      The  situation    i- 


188  PHYSICAL    DIAGNOSIS. 

usually  on  the  posterior  aspect  of  the  chest.  These 
signs  do  not  suffice  for  a  positive  diagnosis  without 
the  characteristic  breath  and  expectoration.  Cavern- 
ous signs  may  appear  after  the  gangrenous  portion 
of  lung  has  sloughed  away  and  been  expectorated. 

Pulmonary  (Edema. 

The  physical  condition  expressed  by  the  term  pul- 
monary a3dema  is  the  presence  of  effused  serum 
within  the  air-vesicles.  "With  this  condition  is  asso- 
ciated more  or  less  pulmonary  congestion. 

In  cases  of  pulmonary  oedema  developed  rapidly 
and  largely  in  connection  with  renal  disease,  with 
obstruction  at  the  mitral  orifice  of  the  heart,  or  with 
both  these  affections  combined,  giving  rise  to  great 
dj'spncea,  and  liable  to  end  speedily  in  death,  the 
following  are  the  diagnostic  signs:  Dulness  on  per- 
cussion on  both  sides  of  the  chest,  especially  over  the 
lower  lobes,  fine  bubbling  or  so-called  subcrepitant 
rales  diffused  over  the  chest  on  both  sides,  together 
with  coarser  bubbling  sounds,  and  the  murmur  of 
respiration  notably  weak  or  suppressed  over  the 
lower  lobes.  Inasmuch  as  the  lungs  are  not  solidi- 
fied the  rales  are  low  in  pitch.  The  vocal  signs  of 
solidification  are,  of  course,  wanting.  Occasionally 
the  crepitant  rale  is  mingled  with  the  fine  bubbling 
sounds. 

This  form  of  the  affection  is  to  be  differentiated 
from  hydrothorax  with  large  effusion,  and  from  so- 
called  capillary  bronchitis.  Hydrothorax  is  always 
associated  with  more  or  less  anasarca,  or  general 
dropsy,  whereas,  pulmonary  oedema,  even  when  de- 
pendent on  renal  disease,  may  occur  without  drop- 


PULMONARY    (EDEMA.  189 

sical  effusion  elsewhere.  Moreover,  the  presence  of 
liquid  within  the  pleural  cavities,  and  its  amount, 
may  always  be  determined  demonstratively  in  cases 
of  hydrothorax  (vide  Pleurisy  with  effusion  and  Ily- 
drothorax).  Capillary  bronchitis  occurs  chiefly  in 
children.  The  so-called  subcrepitant  rale  on  both 
sides  of  the  chest  is  the  diagnostic  sign  of  this  affec- 
tion, but  it  is  not  accompanied  by  dulness  on  per- 
cussion, except  in  so  far  as  the  bronchitis  may  be 
associated  with  lobular  pneumonia  or  collapse  of 
pulmonary  lobules.  The  rapid  development  of  the 
cedema  and  its  pathological  connections,  are  diag- 
nostic points  to  be  taken  into  account. 

Pneumonia  is  excluded  by  the  fact  that  the  affec- 
tion is  at  the  beginning  bilateral,  and  by  the  absence 
of  the  signs  of  solidification  of  lung. 

Pulmonary  cedema  less  in  degree  and  diffusion, 
has,  of  course,  the  same  signs,  not  as  marked  and 
not  as  extensive,  namely,  dulness  on  percussion  and 
line  bubbling  sounds  or  the  so-called  subcrepitant 
rales.  In  this  form  the  affection  is  bilateral,  and 
seated  especially  in  the  posterior  and  inferior  por- 
tions of  the  lungs.  Moreover,  this  form  has  the 
same  pathological  connections,  namely,  with  disease 
of  the  kidneys,  and  mitral  lesions  of  the  heart.  The 
low  pitch  of  the  bronchial  rales,  and  the  absence  of 
the  respiratory  and  vocal  signs  of  solidification,  to- 
gether with  the  fact  of  the  affection  being  bilateral, 
and  the  coexistence  of  disease  of  the  heart  or  kidneys, 
constitute  the  basis  of  a  positive  diagnosis. 

Eypostatic  congestion  of  the  lungs  may  occasion 
a  certain  amounl  of  pulmonary  oedema.  The  physi- 
cal diagnosis   is   to  be  based  OD    bilateral  dulness  on 


190  PHYSICAL    DIAGNOSIS. 

the  posterior  aspect  of  the  chest,  with  low-pitched, 
tine  bubbling  sounds,  or  the  so-called  subcrepitant 
rales  on  both  sides,  these  signs  occurring  under 
circumstances  which  lead  to  the  supposition  of  this 
form  of  congestion. 

Carcinoma  of  Lung- — Tumors  within  the  Chest. 

Carcinomatous  growths  in  the  lungs  are  usually 
in  the  form  of  nodules  varying  in  size  from  that  of 
a  pea  to  a  hen's  egg,  disseminated  throughout  one 
lung  or  both  lungs,  in  greater  or  less  numbers. 
These  disseminated  nodules,  if  of  small  size,  have 
no  well-marked,  definite  diagnostic  signs.  If  limited 
to  a  lung,  or  if  greater  in  number  in  one  lung,  they 
may  occasion  an  appreciable  dulness  on  percussion. 
They  may  also  occasion  feebleness  of  the  respiratory 
murmur,  and,  owing  to  coexisting  circumscribed 
bronchitis,  moist  bronchial  rfiles  may  be  heard  at 
different  points.  These  signs  warrant  a  diagnosis 
when,  as  is  usually  the  case,  cancer  is  known  to 
have  existed  elsewhere.  With  reference  to  diagnosis, 
it  is  to  be  borne  in  mind  that,  when  cancer  of  the 
lung  is  secondary,  both  lungs  are  affected,  and,  when 
it  is  primary,  the  affection  is  generally  unilateral. 

If  there  be  nodules  of  considerable  size,  there  will 
be  well-marked  dulness  on  percussion  in  different 
situations,  and  the  signs  of  solidification  may  be 
present,  namely,  either  bronchial  or  broncho-vesicular 
respiration,  either  increased  vocal  resonance  or 
bronchophony,  and  increased  vocal  fremitus. 

In  some  cases  of  unilateral  carcinoma,  the  greater 
part,  or  the  whole,  of  a  lung  may  be  infiltrated  with 


CARCINOMA    OF    LUNG.  191 

the  morbid  growth,  increasing  its  volume  and  giving 
rise  to  enlargement  of  the  affected  side,  diminished 
respiratory  movements  or  immobility,  flatness  on 
percussion,  with  diminished  or  suppressed  respira- 
tory murmur,  vocal  resonance,  and  fremitus.  If,  as 
is  usual,  there  be  also  more  or  less  pleuritic  effusion, 
the  intercostal  spaces  may  be  pushed  out  to  a  level 
with  the  ribs.  Here  are  the  signs  which  denote 
chronic  pleurisy  with  large  effusion,  and  the  differ- 
ential diagnosis  cannot  be  made  with  positiveness 
until  the  fluid  within  the  chest  be  withdrawn,  and  it 
be  found  that,  irrespective  of  the  bulging  of  the 
intercostal  spaces,  the  physical  signs  remain.  Ex- 
ploration with  a  small  trocar,  or  hollow  needle,  will 
settle  the  diagnosis  when  there  is  no  pleuritic  effu- 
sion, and  this  procedure  is  unobjectionable. 

In  other  cases  the  carcinomatous  growth  induces 
atrophy  of  the  lung,  diminishing  its  volume,  and 
causing  notable  contraction  of  the  affected  side.  The 
appearances  on  inspection  are  those  which  denote 
contraction  after  chronic  pleurisy,  and  they  may  be 
present  also  in  cases  of  fibroid  phthisis  or  cirrhosis 
of  lung.  The  differential  diagnosis  must  be  based 
chiefly  on  diagnostic  points  relating  to  the  history 
and  symptoms. 

Tumors  within  the  chest,  generally  having  their 
points  of  departure  in  the  mediastinum,  displace  the 
lung  in  proportion  to  their  size.  They  may  cause 
considerable  displacement  of  the  heart,  and  produce 
more  or  less  enlargement  of  the  chest  with  dimin- 
ished respiratory  movements.  Enlargement  of  the 
sii  hen  tin  i  eons  veins,  indicative  of  venous  obstruction, 
is  often  to  be  observed.     <  Iver  the  site  of  the  tumor, 


192  PHYSICAL    DIAGNOSIS. 

there  will  be  either  dulness  or  flatness  on  percussion. 
Generally  respiratory  sound  is  wanting,  vocal  reso- 
nance and  fremitus  being  either  diminished  or  sup- 
pressed. In  the  neighborhood  of  the  primary 
bronchi  and  over  lung  compressed  by  the  tumor, 
there  may  be  bronchial  respiration,  with  broncho- 
phony and  increased  fremitus.  If  the  chest  be  en- 
larged, its  enlargement  is  not  likely  to  be  as  uniform 
as  when  it  is  dilated  with  liquid;  this  is  a  diagnostic 
point.  The  tumor,  or  the  tumors,  may  not  be  con- 
fined to  one  side  of  the  chest.  It  is  to  be  borne  in 
mind  that  pleurisy  with  effusion  may  exist  as  a 
complication,  and  this  may  serve  to  obscure  the 
diagnosis. 

The  physical  diagnosis  involves  differentiation 
from  pericarditis  with  effusion  and  aneurisms. 
These  affections  are  to  be  excluded  by  the  absence 
of  their  diagnostic  signs. 

Acute  Miliary  Tuberculosis. 

The  physical  condition  in  this  affection  is  the 
presence  of  a  large  number  of  the  small  bodies 
known  as  tubercles  or  miliary  granulations,  dissemi- 
nated throughout  both  lungs.  Bronchitis  is  an 
associated  affection. 

If  the  tubercles  be  about  equally  distributed  in 
the  two  lungs,  there  is  no  abnormal  disparity  of  the 
resonance  on  percussion  between  the  two  sides  of 
the  chest.  A  comparison,  also,  of  the  two  sides  may 
afford  no  disparity  as  regards  the  respiratory  mur- 
mur, vocal  resonance,  and  fremitus.  Moist  rales, 
due  to  the  associated  bronchitis,  may  be  present  in 


PHTHISIS.  193 

different  situations.  A  physical  diagnosis,  under 
these  circumstances,  cannot  be  made  with  positive- 
ness.  Physical  exploration,  however,  is  important 
in  order  to  exclude  other  affections  ;  and  the  negative 
result,  taken  in  connection  with  the  symptoms — 
hyperpyrexia,  rapid  pulse,  accelerated  breathing, 
etc. — renders  the  diagnosis  extremely  probable. 
The  differential  diagnosis  involves  discrimination 
from  capillary  bronchitis,  and  an  essential  fever  with 
a  bronchial  complication.  The  affection  has  been 
repeatedly  mistaken  for  typhoid  fever. 

The  tubercles  may  be  more  abundantly  distributed 
in  one  lung.  A  disparity  in  the  resonance  on  per- 
cussion may  then  be  apparent,  and,  perhaps,  an 
abnormal  increase  of  vocal  resonance  and  fremitus. 
These  signs,  taken  in  connection  with  the  symptoms, 
establish  the  physical  diagnosis. 

Phthisis. 

With  reference  to  physical  diagnosis,  cases  of 
phthisis  may  be  conveniently  distributed  into  three 
groups,  as  follows  :  1st.  Cases  in  which  the  pul- 
monary affection  is  small,  or  cases  of  incipient 
phthisis;  2d.  Cases  in  which  the  affection  is  mod- 
erate or  considerable;  and,  3d.  Cases  in  which  the 
affection  has  progressed  to  tlie  formation  of  cavities, 
or  cases  of  advanced  phthisis. 

In  cases  of  incipient  phthisis,  the  essential  physical 
condition  is  the  presence  of  small  solidified  masses, 
Or  nodules,  the  intervening  vesicular  structure  not 
being  affected.  These  nodules  vary  from  the  size 
of  a  pea  to  a  filbert.      In    the  vast  majority  of  cases 

17 


194  PHYSICAL    DIAGNOSIS. 

they  are  situated  at  or  near  the  apex  of  either  the 
right  or  the  left  lung.  Generally,  circumscribed 
capillary  bronchitis  coexists  in  proximity  to  the 
nodules.  An  intercurrent  circumscribed  pneumonia 
sometimes  occurs,  giving  rise  to  transient  solidifica- 
tion within  a  limited  area.  Dry  circumscribed 
pleurisy  situated  over  the  affected  portion  of  lung, 
generally  occurs  from  time  to  time. 

In  the  cases  of  a  moderate  or  a  considerable  pul- 
monary affection,  the  difference,  as  compared  with 
the  preceding  group  of  cases,  consists  in  the  presence 
of  nodules  of  larger  size,  or  solidification  from  the 
phthisical  deposit  extending  over  a  space,  or  spaces, 
sufficient  in  size  to  give  rise  to  well-marked  physical 
signs.  The  solidification  in  these  cases  may  be  ex- 
tended by  the  development  of  circumscribed  inter- 
stitial pneumonia.  The  circumscribed  bronchitis  is 
greater,  as  a  rule,  in  degree  and  extent ;  attacks  of 
dry  pleurisy  may  continue  to  occur,  and  the  pleural 
surface  becomes  adherent.  In  these  cases,  generally, 
the  affection,  existing  primarily  in  one  lung,  now 
exists  in  both  lungs.  The  volume  of  the  lung  first 
affected,  at  the  summit,  is  more  or  less  diminished. 
Enlargement  of  the  bronchial  glands  is  usual,  and 
these  may  be  so  situated  as  to  press  upon  and  dim- 
inish the  calibre  of  one  of  the  primary  bronchi.  In 
some  cases,  portions  of  lung  in  the  neighborhood  of 
solidified  masses  or  nodules  are  emphysematous 
(vicarious  emphysema). 

Cases  of  advanced  phthisis  are  characterized  by 
the  presence  of  a  cavity,  or,  commonly,  of  cavities, 
varying  in  number,  size,  rigidity  or  flaceidity  of  the 
walls,   freedom    of  communication   with    bronchial 


PHTHISIS.  195 

tubes,  and  the  nearness  of  their  situation  to  the  super- 
ficies of  the  lung.  In  cases  of  progressive  phthisis,  in 
addition  to  cavities,  there  is  more  or  less  solidification 
from  phthisical  exudation  and  interstitial  pneumonia. 
The  volume  of  the  lung  at  the  summit  is  often  nota- 
bly diminished.  The  pleural  surfaces  are  firmly 
adherent.  If,  however,  the  disease  have  been  retro- 
gressive or  non-progressive,  there  may  be  little  or  no 
solidification  of  lung,  the  cavity  or  cavities  forming 
the  only  lesion.  In  cases  of  advanced  phthisis,  with 
very  rare  exceptions,  both  lungs  are  affected,  and 
cavities  often  exist  on  both  sides. 

The  physical  diagnosis  in  cases  of  incipient  phthisis 
embraces  what  may  be  called  direct  and  accessory 
signs.  The  accessory  signs  are  those  which  repre- 
sent incidental  affections,  namely,  circumscribed 
bronchitis,  pleurisy,  and  pneumonia.  The  direct 
signs  are  those  representing  the  essential  condition, 
namely,  the  solidified  masses  or  nodules. 

An  important  direct  sign  is  dulness  on  percussion. 
Slight  dulness  on  percussion  at  the  summit  of  the 
chest,  in  front  or  behind,  is  a  highly  important  sign, 
taken  in  connection  with  symptoms,  of  incipient 
phthisis.  In  determining  that  a  relative  dulness  is 
abnormal,  the  student  must  bear  in  mind,  in  the 
first  place,  the  normal  disparity  between  the  two 
Bides.  The  right  >ide  at  the  summit  is  relatively 
somewhat  dull  on  percussiou  in  healthy  persons. 
Due  allowance  is  to  be  made  for  this  normal  dis- 
parity. In  tin'  second  place,  it  is  to  be  borne  in 
mind  that  any  deformity  affecting  the  symmetry  of 
the  chest  will  affect  the  relative  resonance  on  the 
two  sides;  and  that  a  deviation  from  symmetry  at- 


196  PHYSICAL    DIAGNOSIS. 

tributable  to  the  position  of  the  patient  will  occa- 
sion a  disparity  on  percussion.  In  the  third  place, 
the  rules  for  the  practice  of  percussion  must  be  kept 
in  mind,  in  order  to  avoid  producing  apparently  an 
abnormal  disparity  by  the  non-observance  of  these 
rules  (vide  p.  60).  Normal  resonance  on  percussion 
on  the  two  sides  is  a  strong  point  for  the  exclusion 
of  incipient  phthisis. 

The  direct  respiratory  signs  in  incipient  phthisis 
are  the  broncho-vesicular  respiration  and  weakened 
vesicular  murmur.  To  these  is  to  be  added  a  local- 
ized interrupted  or  wavy  inspiratory  murmur  as  an 
occasional  sign.  Of  course,  familiarity  with  the 
characters  of  the  broncho-vesicular  respiration  is 
indispensable — the  combination  of  the  vesicular  and 
the  tubular  quality  in  the  inspiratory  sound,  with 
the  pitch  raised  in  proportion  to  the  amount  of 
tubularity,  and  the  expiratory  sound  more  or  less 
prolonged,  high,  and  tubular.  Not  infrequently  the 
only  appreciable  morbid  modification  is  diminished 
intensity  of  the  murmur.  When  this  sign  is  present, 
it  is  probable  that  the  lack  of  intensity  is  the  reason 
for  the  absence  of  the  characters  of  the  broncho- 
vesicular  modifications,  that  is,  the  latter  sign  would 
have  been  present  were  the  respirator}7  sounds  more 
intense. 

The  direct  vocal  signs  in  incipient  phthisis  are,  in- 
creased vocal  resonance,  increased  bronchial  whisper, 
and  increased  fremitus.  The  other  direct  signs  may 
be  present  without  an  appreciable  morbid  increase 
of  the  vocal  resonance  or  fremitus.  The  increased 
whisper  may  also  be  wanting,  but  more  rarely  than 
the  two  other  vocal  signs. 


PHTHISIS.  107 

In  deciding  on  the  presence  or  absence  of  each 
and  all  of  these  direct  signs,  it  is  essential  to  kilob- 
aud to  judge  correctly  of  the  disparity  between  the 
two  sides  of  the  chest  at  the  summit  in  health. 
Normally  the  resonance  on  percussion  at  the 
summit  on  the  right  side  is  slightly  dull  as  com- 
pared with  the  left  side;  the  inspiratory  sound  on 
this  side  ha3  some  tubularity  in  quality,  and  is 
somewhat  raised  in  pitch;  the  expiratory  sound 
may  be  more  or  less  prolonged,  high,  and  tubular: 
the  vocal  resonance  on  the  right  side  is  always 
greater,  the  same  being  true  of  fremitus  :  the  bron- 
chial whisper  is  louder  on  the  right  side,  and  the 
intensity  of  the  respiratory  murmur  is  a  little  less 
on  this  side.  Whenever  it  is  a  question  as  to  a 
small  phthisical  affection  at  or  near  the  apex  of  the 
right  lung,  it  is  a  matter  of  experience  and  judgment 
to  decide  if  the  disparity  in  respect  of  these  points 
be  greater  than  normal,  and  it  is  not  always  easy  to 
come  at  once  to  a  decision.  From  the  want  of  a 
proper  appreciation  of  the  several  points  of  disparity 
in  health,  it  is  not  uncommon  for  an  erroneous  diag- 
nosis of  phthisis  to  be  based  thereon.  Appreciating 
the  normal  points  of  disparity,  it  is  obviously  easier 
to  determine  that  the  several  direct  signs  of  incipient 
phthisis  are  present  at  the  left  than  at  the  right 
summit  ;  relative  dulness  on  percussion,  broncho- 
vesicular  or  weakened  respiration,  increased  vocal 
•nance,  whisper,  and  fremitus,  at  the  left  summit 
are,  of  course,  always  abnormal. 

In  connection  with  the  foregoing  direct  Bigns  may 
be  mentioned  another  sign  which  is  often  available, 
namely,   an   abnormal    transmission    of  the   heart* 

17* 


198  PHYSICAL    DIAGNOSIS. 

sounds.  This  sign  is  available  only  in  the  central 
portion  of  the  infra-clavicular  region.  A  slight  de- 
gree of  solidification  of  the  summit  of  one  lung 
renders  the  heart-sounds  more  audible  in  the  situa- 
tion just  named.  It  is  of  assistance  in  determining 
this  sign  to  be  familiar  with  the  following  points  of 
disparity  which  exist  in  health :  on  the  right  side 
the  second  sound  of  the  heart  is  somewhat  more 
audible  than  on  the  left  side,  and  on  the  left  side 
the  first  sound  is  a  little  louder  than  on  the  right 
side.  Hence,  if  the  first  sound  be  better  transmitted 
on  the  right  than  on  the  left  side,  it  is  abnormal; 
and  if  the  second  sound  be  louder  on  the  left  side, 
it  is  abnormal.  This  sign  is  always  to  be  taken  in 
connection  with  other  direct  signs ;  it  gives  greater 
diagnostic  strength  to  the  latter,  but  it  is  by  no 
means,  in  itself,  sufficient  for  the  diagnosis. 

Corroborative  evidence  of  incipient  phthisis  may 
be  obtained  by  the  presence  of  accessory  signs. 
These  are:  First,  fine  bubbling  or  the  so-called  sub- 
crepitant  rale  at  the  summit  on  one  side.  This 
sign  denotes  a  circumscribed  capillary  bronchitis, 
and  this,  at  the  summit  on  one  side,  is  usually  asso- 
ciated with  phthisis.  Second,  a  crepitant  rale  at  the 
summit  on  one  side  denotes  a  circumscribed  pneu- 
monia which  is  usually  secondary  to  phthisis.  Third, 
a  pleuritic  friction-sound  limited  to  the  summit  on 
one  side  is  evidence  of  a  dry  circumscribed  pleurisy 
which  occurs  often  in  the  early  stage  of  phthisis. 
Fourth,  indeterminate  rales,  crumpling  and  crack- 
ling, are  significant  of  phthisis  if  limited  to  the 
summit  on  one  side.  These  rales,  it  is  to  be  recol- 
lected, are   sometimes  found  in  healthy  persons  on 


PHTHISIS.  199 

forced  breathing,  especially  if  the  binaural  stetho- 
scope be  employed.  If  they  be  normal  they  are 
found  on  both  sides.  The  accessory  signs  are  not 
sufficient  for  a  positive  diagnosis  if  they  exist  alone; 
but  they  are  to  be  considered  as  corroborating  the 
evidence  derived  from  the  direct  signs,  together 
with  the  symptoms  and  history.  It  is  of  service 
often  in  bringing  out  the  rales  to  cause  the  patient 
to  cough. 

As  regards  differential  diagnosis,  the  affections 
with  which  incipient  phthisis  is  likely  to  be  con- 
founded are  chronic  bronchitis  and  moderate  em- 
physema. With  respect  to  the  first  of  these  affec- 
tions, namely,  bronchitis,  the  differentiation  must 
depend  on  the  presence  or  the  absence  of  positive 
signs  of  phthisis;  in  other  words,  phthisis  is  either 
diagnosticated  or  excluded.  The  physical  signs  in 
cases  of  moderate  emphysema  sometimes  lead  to 
the  error  of  supposing  this  affection  to  be  phthisis. 
Owing  to  the  relatively  greater  intensity  of  the 
resonance  on  percussion  at  the  left  summit,  dulness 
is  thought  to  exist  at  the  right  summit,  and  a  pro- 
longed expiration,  with  the  normally  greater  vocal 
resonance  at  the  right  summit,  are  regarded  as  signs 
of  phthisis.  This  error  may  be  avoided  by  a  careful 
study  of  the  signs  of  emphysema  and  the  normal 
disparity  in  respiration,  vocal  resonance,  and  fre- 
mitus, existing  between  the  two  sides  of  the  chest. 

The  physical  diagnosis  of  a  phthisical  affection 
which  is  considerable  or  moderate  in  amount,  is,  in 
most  cases,  an  easy  problem.  Inspection  often  fur- 
nishes marked  signs.     The  upper  anterior  portion 


200  PHYSICAL    DIAGNOSIS. 

of  the  chest  on  one  side  is  depressed  or  flattened, 
and  the  superior  costal  movements  of  respiration 
are  diminished,  the  chest  elsewhere  being  sym- 
metrical in  both  size  and  motions.  There  is  more 
or  less  marked  dulness  on  percussion  at  the  upper 
part  of  the  chest  on  the  affected  side.  Sometimes 
the  diminished  resonance  is  tympanitic  in  quality 
(tympanitic  dulness)  without  the  existence  of  cavi- 
ties, the  resonance  being  transmitted  from  the  pri- 
mary and  secondary  bronchial  tubes.  The  respiration 
is  either  bronchial  or  broncho-vesicular  approximat- 
ing more  or  less  to  the  bronchial.  Occasionally,  how- 
ever, the  respiratory  sounds  are  too  feeble  for  their 
characters  to  be  appreciated.  There  is  either  bron- 
chophony, or  the  vocal  resonance  is  notably  increased 
without  the  bronchophonic  characters.  The  whisper 
is  either  distinctly  bronchophonic  or  it  is  notably  in- 
creased in  intensity,  high  in  pitch,  and  tubular  in 
quality.  Vocal  fremitus  is  often  increased.  Moist 
bronchial  rales,  coarse  or  fine,  are  generally  present. 
With  these  diagnostic  signs  on  one  side,  the  signs  of 
a  smaller  amount  of  disease  are  generally  present  on 
the  other  side. 

In  some  cases  of  a  moderate  phthisical  affection, 
the  judgment  may  be  confused  by  the  resonance  on 
percussion  being  increased  or  vesiculotympanitic 
on  the  affected  side.  This  sign  denotes  the  coex- 
istence of  emphysematous  lobules  (vicarious  emphy- 
sema) developed  in  the  progress  of  phthisis.  The 
diagnosis  of  the  latter  affection  is  then  to  be  based 
on  the  signs  obtained  by  auscultation. 

In  advanced  phthisis  the  physical  diagnosis  of  the 
disease  is  easy.     The  signs  distinctive  of  this  stage 


FIBKOIU    PHTHISIS,  ETC.  201 

of  the  disease  are  those  which  denote  pulmonary 
cavities,  namely,  tympanitic  resonance  on  percus- 
sion within  a  circumscribed  space;  cracked  metal 
or  amphoric  resonance;  cavernous  respiration  ;  cav- 
ernous whisper  and  sometimes  pectoriloquy ;  am- 
phoric respiration  and  voice,  and  gurgling  (vide 
Chapter  V.  for  description  of  these  signs). 

The  cavernous  signs  are  generally  associated  with 
the  signs  of  solidification.  In  some  cases,  however, 
in  which  the  disease  has  been  non-progressive  and 
retrogressive,  the  cavernous  signs  are  present  with- 
out the  signs  which  denote  solidification  of  lung. 

Fibroid  Phthisis — Interstitial  Pneumonia,  or  Cirrhosis 
of  Lung-. 

In  this  affection  the  physical  conditions  are,  solidi- 
fication from  hyperplasia  of  the  interstitial  pulmonary 
tissue,  dilatation  of  bronchial  tubes  (bronchiectasis), 
and  diminished  volume  of  the  lung  affected.  The 
affection,  as  a  rule,  is  either  limited  to  or  especially 
marked  on  one  side.  The  whole  of  a  lung,  or  only 
a  portion  of  it,  may  be  affected.  Bronchitis  always 
coexists. 

There  is  notable  dulness  on  percussion,  the  di- 
minished resonance  being  sometimes  tympanitic. 
The  degree  of  resonance  may  vary  at  different  ex- 
aminations, owing  to  differences  in  the  amount  of 
morbid  products  within  the  bronchial  tubes.  The 
respiration  is  bronchial,  or  broncho-vesicular.  At 
times,  from  obstruction  of  bronchial  tubes,  it  may 
be  suppressed.  Bronchophony  and  increased  vocal 
resonance  arc  the  vocal  Bigns,  together  with  the 
corresponding  whispering  Bigns.     The  Bide  oi   the 


202  PHYSICAL    DIAGNOSIS. 

chest  which  is  chiefly  or  exclusively  affected  be- 
comes contracted  either  entirely  or  in  part,  resem- 
bling in  this  respect  the  appearances  after  chronic 
pleurisy. 

With  these  signs  the  affection  is  to  be  differen- 
tiated from  the  ordinary  form  of  phthisis,  by  refer- 
ence to  points  pertaining  to  the  symptoms  and 
history. 

Diaphragmatic  Hernia. 

The  presence  of  more  or  less  of  the  abdominal 
viscera  within  the  thoracic  cavity  in  consequence  of 
a  congenital  deficiency  of  a  portion  of  the  diaphragm, 
or  perforation  from  accidents,  or  enlargement  of  the 
natural  openings,  gives  rise  to  certain  anomalous 
signs,  namely,  a  tympanitic  resonance,  variable  at 
different  times  owing  to  differences  as  regards  the 
quantity  of  gas  within  the  viscera;  absence  of  the 
respiratory  murmur  from  the  base  of  the  chest 
upward,  the  height  proportional  to  the  space  oc- 
cupied by  the  abdominal  organs,  and  the  intestinal 
sounds  emanating  from  within  the  chest,  not  con- 
ducted from  below. 

This  extremely  rare  affection  can  only  be  con- 
founded with  pneumothorax.  The  latter  affection 
is  to  be  excluded  by  the  absence  of  its  diagnostic 
signs,  irrespective  of  the  tympanitic  resonance  on 
percussion. 


CHAPTER  VII. 

THE  PHYSICAL  CONDITIONS  OF  THE  HEART  IN 
HEALTH  AND  DISEASE.  THE  HEART-SOUNDS  AND 
CAKDIAC  MURMURS. 

Physical  conditions  of  the  heart  in  health:  Boundaries  of  the  prSBCOrdia 
— Normal  situation  of  the  apex-beat — Boundaries  of  the  deep  and  of  the 
superficial  cardiac  space — Relations  of  the  aorta  and  the  pulmonary 
artery  to  the  walls  of  the  chest — The  heart-sounds — Characters  dis- 
tinguishing the  first  and  the  second  sound — Mechanism  of  the  produc- 
tion of  the  heart-sounds — Auscultation  of  the  pulmonic  and  the  aortic 
second  sound  separately — Movements  of  the  auricles  and  ventricles  in 
relation  to  each  other — Physical  conditions  of  the  heart  in  disease: 
Enlargement  of  the  heart — Hypertrophy  and  dilatation — Abnormal 
impulses  of  the  heart,  and  modifications  of  the  apex-beat — Valvular 
lesions— Roughness  of  the  pericardial  surfaces — Liquid  within  the 
pericardial  sac — Abnormal  modifications  of  the  heart-sounds — Re- 
duplication of  heart-sounds — Cardiac  murmurs — Normal  and  abnormal 
blood-currents  within  the  heart,  and  their  relations  with  the  heart- 
sounds —  Mitral  direct  murmur — Mitral  regurgitant  murmur — Mitral 
systolic  non-regurgitant,  or  intra- ventricular  murmur — Aortic  direct 
murmur — Aortic  regurgitant  murmur,  and  in  Aortic  diastolic  non- 
regurgitant  murmur — Coexisting  endocardial  murmurs  —  Tricuspid 
direct  murmur  —  Tricuspid  regurgitant  murmur — Pulmonic  direct 
murmur — Pulmonic  regurgitant  murmur — Facts  of  practical  impor- 
tance in  relation  to  endocardial  murmurs  —  Pericardial  or  friction 
murmur. 

Before  entering  upon  the  study  of  the  physical 
diagnosis  of  the  diseases  of  the  heart,  the  student 
must  be  familiar  with  its  anatomy  and  physiology. 
For  a  description  of  the  structure  and  functions  of 
this  organ,  he  is  referred  to  anatomical  and  physio- 
logical treatises,  The  plan  of  this  work  emhraces 
the  anatomical  relations  of  the  heart  and  the  space 


204  THE    HEART. 

which  it  occupies  within  the  chest,  as  physical  con- 
ditions of  health  determinable  by  normal  signs, 
together  with  the  heart-sounds.  Having  briefly 
stated  these  conditions  of  health,  the  morbid  physical 
conditions  which  may  be  ascertained  by  percussion, 
auscultation,  and  other  methods  of  physical  explora- 
tion, will  be  considered.  The  latter  heading  will 
include  an  account  of  the  cardiac  murmurs. 

The  Physical  Conditions  of  the  Heart  in  Health. 

The  Prcecordia — The  Superficial  and  the  Deep  Cardiac 
Space. — The  area  on  the  surface  of  the  chest  corre- 
sponding to  the  space  which  the  heart  occupies 
within  the  chest,  is  the  precordial  region  or  the 
prsecordia.  The  upper,  lower,  and  two  lateral 
boundaries  of  this  region  must  be  memorized.  The 
upper  boundary  is  the  third  rib,  the  lower  is  a  hori- 
zontal line  passing  through  the  fifth  intercostal 
space ;  the  left  lateral  boundary  is  at,  or  a  little 
within,  a  vertical  line  passing  through  the  nipple, 
the  tinea  mammillaris,  and  the  right  lateral  boundary 
is  represented  by  a  vertical  line  situated  about  a 
finger's  breadth  to  the  right  of  the  right  margin  of 
the  sternum.  As  the  volume  of  the  heart  varies, 
within  certain  limits,  in  different  healthy  persons, 
the  boundaries  of  the  prsecordia  are,  of  course,  not 
always  exactly  the  same.  The  foregoing  statements 
are  sufficiently  accurate  for  practical  purposes. 

The  horizontal  line  representing  the  lower  boun- 
dary of  the  prsecordia  intersects  the  point  where  the 
apex-beat  of  the  heart  is  felt.  The  normal  situation 
of  the   apex-beat   must   be    recollected.      In    most 


CONDITIONS    OF    HEART    IN    HEALTH.      205 

healthy  persons  the  apex-beat  is  felt  in  the  fifth 
intercostal  space,  a  little  within  the  linea  mammil- 
laris.  This  is  assuming  the  persons  to  be  sitting  or 
standing;  in  recumbency  on  the  back  the  beat 
sometimes  rises  to  the  fourth  intercostal  space,  and 
it  is  sometimes  found  in  the  fourth  space  in  the  sit- 


FlG.   11. 


ting  or  standing  position  of  the  body.  The  distance 
from  the  linea  niaiuniillaris  varies  in  different  healthy 
persons;  it  is  sufficiently  accurate  tosayit  is  a  little 
within  that  line.  (Fig.  11.)  The  force  of  the  japex- 
beal  varies  much  in  different  healthy  persons,  owing 

to  Other  causes  than  the  power  of  the  heart's  action, 

is 


206  THE    HEART. 

such  as  the  amount  of  muscular  substance  and  fat  in 
that  situation,  the  width  of  the  intercostal  space,  the 
convexity  of  the  chest,  the  relation  to  the  left  lung, 
etc.  Allowance  is  to  be  made  for  these  variations 
in  determining  the  abnormal  modifications  of  the 
force  of  the  beat,  which  belong  among  the  physical 
signs  of  disease. 

Within  a  portion  of  the  prsecordia  the  heart  is 
uncovered  of  lung,  and  in  the  remaining  portion 
lung  intervenes  between  the  heart  and  the  walls  of 
the  chest.  The  former  of  these  portions  is  called 
the  superficial,  and  the  latter  is  called  the  deep 
cardiac  space.  The  deep  cardiac  space  on  the  right 
side  extends  to  the  median  line.  On  the  left  side 
the  lung  recedes  at  a  point  on  the  median  line  on  a 
level  with  the  cartilage  of  the  fourth  rib,  and  the 
anterior  border  of  the  upper  lobe  makes  an  outward 
curve,  returning  inward  at  or  near  the  apex  of  the 
heart.  This  leaves  the  heart  uncovered  within  an 
area  which,  for  practical  purposes,  may  be  repre- 
sented by  a  right-angled  triangle,  the  hypothenuse 
extending  from  the  median  line  on  a  level  with  the 
costal  cartilage  of  the  fourth  rib  to  the  apex  of  the 
heart;  the  right  angle  formed  by  the  median  line 
and  the  horizontal  line  which  forms  the  lower  boun- 
dary of  the  prsecordia.     (Figs.  11  and  12.) 

The  limits  of  the  superficial  cardiac  space  may  be 
easily  defined  by  percussion.  It  is  only  necessary  to 
ascertain  the  curved  line  formed  by  the  receding 
anterior  border  of  the  upper  lobe  of  the  left  lung. 
A  distinct,  although  not  great,  dulness  on  percussion 
marks  this  border  of  the  lung.  The  border  of  the 
lung  is  as  distinctly  marked  by  the  abrupt  diminu- 


CONDITIONS    OF    HEART    IN    HEALTH       207 

tion  of  the  vocal  resonance,  if  auscultation  be  made 
with  the  stethoscope.  The  outer  boundaries  of  the 
deep  cardiac  space  may  also  be  determined  by  per- 
cussion; distinct,  although  slight  dulness  marks  the 
limits  of  the  praecordia.  Defining  thus  the  boun- 
daries of  the  pnecordia  and  of  the  superficial  cardiac 

Fin    12. 


space   in    healthy    persons,    makes   a   good   practical 
exercise  in  percussion. 

Relations  of  ihv  Aorta  and  Pulmonary  Artery  to  the 

Walls  of  'I"  <  'hest. — The  base  <>f  the  heart,  especially 

in  connection  with  auscultatory  signs,  is  generally 


208  THE    HEART. 

considered  to  be  at  the  second  intercostal  space  near 
the  sternum,  this  situation  being,  in  reality,  just 
above  the  base.  In  this  situation  sounds  produced 
at  the  aortic  and  the  pulmonic  orifice  are  best  studied, 
either  in  health  or  disease.  With  reference  to  these 
sounds,  the  anatomical  relations  of  the  aorta  and  the 
pulmonary  artery  to  the  right  and  the  left  second 
intercostal  space  are  of  importance.  If  the  stetho- 
scope be  applied  in  the  second  intercostal  space  on 
the  right  side,  close  to  the  sternum,  it  is  very  near 
the  aorta,  and  sounds  produced  at  the  aortic  orifice 
are  best  heard  in  this  situation.  If  the  stethoscope 
be  applied  in  the  second  intercostal  space  on  the  left 
side,  it  is  very  near  the  pulmonary  artery,  and  the 
sounds  produced  at  the  pulmonic  orifice  are  best 
heard  in  this  situation.  Reference  will  be  made  to 
these  two  situations  in  giving  an  account  of  the 
heart-sounds  in  health  and  disease,  and  of  adventi- 
tious sounds  or  murmurs.     (Fig.  11.) 

The  Heart-sounds. — It  is  customary  to  consider  the 
heart-sounds  as  two  in  number,  and  to  distinguish 
them  as  the  first,  or  systolic,  and  the  second,  or 
diastolic,  sound.  The  characters  which  distinguish 
the  heart-sounds  in  health  are  to  be  studied  prepara- 
tory to  the  study  of  the  abnormal  modifications 
which  are  important  physical  signs  of  disease.  It  is 
essential  to  be  able  always  to  make  the  distinction 
practically  between  the  so-called  first,  or  systolic, 
and  the  second,  or  diastolic,  sound  in  order  to  con- 
nect with  them  separately  cardiac  murmurs.  The 
conventional  use  of  the  term  heart-sounds,  as  dis- 
tinguished from  cardiac  murmurs,  must  be  borne  in 
mind.       The    cardiac    murmurs    are    adventitious 


CONDITIONS    OF    HEART    IN    HEALTH.      209 

sounds;  they  are  never  merely  abnormal  modifica- 
tions of  the  heart-sounds,  but  they  are  new  sounds 
added  to  or  replacing  these. 

Considering  the  heart-sounds  as  two  in  number, 
namely,  the  first,   or   systolic,  and  the   second,  or 
diastolic,  these  follow  in  a  certain  rhythmical  order, 
and,  in  health,  this  suffices  for  the  recognition  of 
each.     It  answers  all  practical  purposes  to  say  that 
the  sounds  follow  each  other  after  an  interval  which 
is  just  appreciable,  this    interval   being    the    short 
pause  of  the  heart.     After  the  occurrence  of  both, 
an  interval  is  readily  appreciable,   called  the  long 
pause  of  the  heart.     It  is  not  necessary  to  carry  in 
the  memory  the  exact  relative  duration  of  each  of 
the  two  sounds  and  each  of  the  two  intervals.     The 
fractions  of  a  unit,  in  fact,  do  not  express  the  length 
of  the  sounds  and  intervals  as  correctly  as  less  defi- 
nite expressions,  inasmuch  as  the  figures  represent 
only  the  mean  of  variations  within  the   limits  of 
health.     It  is  sufficiently  exact  to  say  that,  with  the 
ear  or  stethoscope  applied  over  the  situation  of  the 
apex-beat,  the   systolic   sound   is  longer   than   the 
diastolic,  louder,  lower  in   pitch,  and  has  a  quality 
which  may  be  called  booming.     Per  contra,  the  dias- 
tolic sound  is  shorter,  weaker,  higher  in  pitch,  and 
has  a  quality  which  may  be  called  valvular  or  click- 
ing.    Aside  from  the  relative  length,  the  other  char- 
acters arc  more  or  less  marked  in  different  healthy 
persons. 

These  distinctive  characters  of  the  systolic  and 
diastolic  heart-sounds  are  apparent  when  the  ear  or 
stethoscope  is  applied  over  the  apex.  Ai  the  base 
of  the  heart,  thai  is,  in  the  Becond  intercostal  space 

18* 


210  THE    HEART. 

near  the  sternum,  the  characters  of  the  systolic  sound 
are  not  the  same  as  over  the  apex.  The  diastolic 
sound  in  this  situation  is  louder  than  the  systolic. 
The  latter  is  said  to  be  accentuated  at  the  base,  the 
systolic  sound  being  accentuated  at  the  apex.  More- 
over the  systolic  sound  at  the  base  may  not  be  longer 
than  the  diastolic;  it  loses  more  or  less  of  its  boom- 
ing quality,  the  pitch  remaining  lower  than  that  of 
the  diastolic  sound.  Removing  the  ear  or  the  steth- 
oscope a  certain  distance  from  the  apex  in  any  direc- 
tion, occasions  similar  changes  in  the  characters  of 
the  systolic  sound.  The  interposition  of  several 
thicknesses  of  a  napkin  has  the  same  effect. 

From  the  differential  characters  over  the  apex,  and 
the  rhythm  alone  in  other  situations,  there  is  no  diffi- 
culty in  distinguishing  the  systolic  from  the  diastolic 
sound  in  health.  In  cases  of  disease,  however,  owing 
to  disturbance  of  the  rhythm,  modifications  of  the 
characters  of  the  systolic  sound,  and  the  absence 
sometimes  of  one  of  the  sounds,  other  means  of 
recognition  must  be  resorted  to.  If  the  apex-beat 
can  be  felt,  this  offers  a  ready  way  for  recognizing 
the  systolic  sound — the  sound  which  is  synchronous 
with  the  apex-beat  is,  of  course,  the  systolic  sound. 
This  mode  is  not  always  available,  inasmuch  as  the 
apex-beat  cannot  always  be  felt.  Another  mode  is 
always  available,  namely,  feeling  the  carotid  pulse. 
The  carotid  pulse  is  synchronous  with  the  systolic 
sound,  whereas  there  is  a  slight  interval  between  this 
sound  and  the  radial  pulse. 

The  student  is  aided,  in  comprehending  certain 
physical  signs  by  taking  into  view  the  mechanism  of 
the  production  of  the  heart-sounds.     The  diastolic 


CONDITIONS    OF    HEART    IN    HEALTH.      211 

sound  is  produced  by  the  sudden  forcible  closure  of 
the  aortic  and  the  pulmonic  valves.  This  closure  is 
caused  by  a  retrograde  movement  of  the  columns  of 
blood  in  the  aorta  and  pulmonary  artery,  directly 
the  ventricular  systole  is  ended.  The  retrograde 
movement  is  due  to  the  recoil  of  the  coats  of  the 
arteries  which  have  been  dilated  by  the  column  of 
blood  moving  onward  during  the  ventricular  systole. 
This  recoil  causes  regurgitation  into  the  ventricle 
when  either  the  aortic  or  the  pulmonic  valve  is  ren- 
dered incompetent  by  lesions.  The  mechanism  of 
the  systolic  sound  is  less  simple.  This  sound  is  in 
part  due  to  the  forcible  tension  of  the  auriculo- 
ventricular  valves,  caused  by  the  systole  of  the  ven- 
tricles. In  this  way  is  produced  a  valvular  element 
of  the  systolic  sound.  That  the  impulsion  of  the 
heart  against  the  walls  of  the  chest  furnishes  another 
element,  seems  demonstrable.  To  this  element  of 
impulsion  the  systolic  sound  is  indebted  for  its  greater 
intensity,  as  compared  with  the  diastolic  sound,  its 
length,  and  its  booming  quality.  This  is  shown  by 
the  fact,  already  stated,  that  when  auscultation  is 
made  at  a  certain  distance  from  the  apex,  these 
characters  are  eliminated,  and  by  the  fact  that  dis- 
eases which  diminish  or  arrest  the  impulsion  move- 
ments of  the  heart  produce  the  same  modifications. 
The  valvular  element  of  the  systolic  sound  is  weaker 
than  the  diastolic  sound,  a  fact  which  at  first  occa- 
sion- surprise  when  the  difference  in  size  between 
the  aortic  and  pulmonic  and  the  auriculo-ventricular 
valves  is  considered.  The  explanation  of  this  appa- 
rent incongruity  is  as  follows:  the  aortic  ami  pul- 
monic Begments  at  the  end  of  the  ventricular  systole 


212  THE    HEART. 

are  in  contact  with  the  arterial  walls,  and  are  ex- 
panded when  the  recoil  of  the  latter  follows.  On 
the  other  hand,  when  the  ventricular  systole  takes 
place  in  health,  the  auriculo-ventricular  valves  are 
not  in  contact  with  the  walls  of  the  ventricles,  but 
they  are  floated  out,  and  the  oritices  are  nearly  or 
quite  closed;  the  movement  of  the  blood,  therefore, 
in  the  systole  only  renders  these  valves  tense.  The 
diastolic  sound,  in  other  words,  is  due  to  the  expan- 
sion of  the  sigmoid  valves  of  the  aorta  and  pulmonary 
artery,  whereas,  the  valvular  element  of  the  systolic 
sound  is  due  to  merely  tension  of  the  auriculo- 
ventricular  valves.  The  foregoing  points  relating  to 
the  heart-sounds  were  contained  in  my  prize  essay 
"  On  the  Clinical  Study  of  the  Heart-sounds  in 
Health  and  Disease,"  published  in  the  Transactions 
of  the  American  Medical  Association,  in  1852.1 

With  reference  to  important  bearings  on  ausculta- 
tion in  disease,  the  diastolic  or  second  sound  is  to  be 
studied  as  produced  at  the  aortic  and  the  pulmonic 
oritice  separately.  Recalling  the  anatomical  rela- 
tions of  the  aorta  and  the  pulmonary  artery  to  the 
walls  of  the  chest,  if  the  stethoscope  be  applied  in 
the  second  intercostal  space  on  the  right  side  close 
to  the  sternum,  the  characters  of  the  diastolic  sound 
are  derived  chiefly  from  the  aortic  valve,  and  if  the 
stethoscope  be  applied  in  the  second  intercostal 
space  on  the  left  side  close  to  the  sternum,  the  char- 
acters of  the  diastolic  sound  are  derived  chiefly  from 
the  pulmonic  valve.  The  correctness  of  this  state- 
ment is  proved  by  differences  in  the  characters  of 

1   Vide,  also,  "  Treatise  on  Diseases  of  the  Heart,"  first  edition, 
1860;  second  edition,  1870. 


CONDITIONS    OF    HEART    IN    HEALTH.      213 

the  sound  on  two  sides  in  health,  and  by  the  modi- 
fications in  cases  of  disease.  These  morbid  modifi- 
cations will  enter  into  the  physical  diagnosis  of  car- 
diac affections.  In  health  the  aortic  diastolic  sound 
is  somewhat  louder,  higher  in  pitch,  and  the  valvular 
quality  more  marked  than  the  pulmonic  diastolic 
sound.  The  student  should  verify  these  points  of 
difference  by  the  study  of  the  diastolic  sound  in  the 
two  situations  just  named.  In  order  for  the  com- 
parison to  be  a  fair  one  in  health,  and  available  in 
the  diagnosis  of  disease,  the  normal  anatomical  re- 
lations to  the  walls  of  the  chest,  of  the  aorta,  and 
pulmonary  artery  must  be  preserved.  These  rela- 
tions are  affected  by  changes  in  the  symmetry  of  the 
chest,  and  sometimes  by  enlargement  of  the  heart. 
The  lungs  must  also  be  free  from  disease  :  otherwise, 
the  transmission  of  the  sounds  will  be  abnormal. 

In  the  account  of  the  mechanism  of  the  production 
of  the  heart-sounds  (vide  page  211),  it  was  stated  that 
the  first  or  systolic  sound  consists  of  a  valvular  ele- 
ment and  an  element  of  impulsion.  This  valvular 
element  is  a  two-fold  sound,  that  is,  it  is  a  combina- 
tion of  a  sound  produced  by  the  mitral  and  a  sound 
produced  by  the  tricuspid  valve.  These  two  valvular 
>v!K-hronous  sounds  may  be  studied  separately  in 
health,  and  their  abnormal  modifications  constitute 
important  diagnostic  signs  in  cases  of  disease.  This 
fact,  which  was  pointed  out  in  my  prize  essay  "  On 
the  Clinical  Study  of  the  Heart-sounds,"  in  1852, 
has  not  received,  as  yet,  from  medical  writers  the 
attention  which  its  importance  deserves. 

The  two  valvular  sounds  may  be  designated  the 
mitral  and  the  tricuspid  systolic  BOnnd.      Adding  to 


214  THE    HEART. 

these  two  sounds,  the  sound  of  impulsion  produced 
by  the  movements  of  the  apex,  with  the  ventricular 
systole,  are  three  distinct  sounds.  The  diastolic  or 
second  sound  of  the  heart,  as  has  been  seen,  is  re- 
solvable into  two  distinct  sounds.  Hence,  the  num- 
ber of  distinct  heart-sounds  is,  in  reality,  live,  two  of 
which  are  diastolic  and  three  systolic,  namely,  the 
mitral  valvular,  the  tricuspid  valvular,  the  sound  of 
impulsion,  the  aortic  and  the  pulmonic.  Each  of 
these  five  sounds  may  be  studied  separately  in  health 
and  disease.  The  abnormal  modifications  of  each 
furnish  important  information  in  diagnosis. 

In  health,  the  sound  of  impulsion  is  heard  over 
the  situation  of  the  apex-beat  of  the  heart.  The 
mitral  valvular  sound  is  studied  by  listening  with 
the  stethoscope  applied  to  the  left  of  the  apex  at  a 
distance  sufficient  to  eliminate  the  sound  of  im- 
pulsion. 

The  tricuspid  valvular  sound  is  heard  at  a  little 
distance  to  the  right  of  the  inferior  border  of  the 
heart. 

In  the  pages  which  follow  I  shall  sometimes  refer 
to  the  systolic  and  the  diastolic  sound  in  the  singular 
number,  it  being  understood  that  the  systolic  sound 
embraces  three,  and  the  diastolic  two,  components; 
and  at  other  times  I  shall  refer  to  the  sounds  sepa- 
rately which  are  combined  in  the  two  sounds.1 

The  order  of  the  succession  of  the  movements  of 
the  auricles  and  of  the  ventricles  is  to  be  kept  in 
mind  with  reference  to  the  comprehension  of  certain 

1   Vide  paper  on  the  clinical  study  of  the  heart-sounds,  by  the 
Author,  in  the  Journal  of  the  American  Med.  Association,  1884. 


CONDITIONS    OF    HEART    IN    DISEASE.      215 

physical  signs  of  disease.  Points  of  especial  impor- 
tance are  the  contraction  of  the  auricles  in  the  latter 
part  of  the  long  pause  of  the  heart,  preceding  the 
ventricular  systole,  and  the  twisting  of  the  heart 
from  left  to  right  in  the  systole,  this  movement  being 
reversed  in  the  diastole.  In  these  systolic  and  dias- 
tolic twisting  movements,  the  pericardial  surfaces 
move  upon  each,  but  in  health  noiselessly  owing  to 
their  smoothness  and  moisture.  The  movements 
occasion  an  auscultatory  sign,  namely,  a  friction 
murmur,  when  the  surfaces  are  roughened  by  the 
presence  of  lymph.  Other  points  are  the  size  of  the 
pericardial  sac,  that  is,  its  capability  of  holding  when 
tilled,  but  not  dilated,  from  fifteen  to  twenty  ounces 
of  liquid,  and  its  attachment,  not  to  the  base  of  the 
heart,  but  to  the  vessels  above  the  base. 

Physical  Conditions  of  the  Heart  in  Disease. 

The  physical  conditions  of  the  heart  in  disease, 
which  are  determinable  by  physical  exploration,  are, 
1st,  enlargement  of  the  heart ;  2d,  abnormal  im- 
pulses and  modifications  of  the  apex-beat;  3d, 
valvular  lesions;  -1th,  roughness  of  the  pericardial 
surfaces:  and,  5th,  liquid  within  the  pericardial  sac. 
Having  considered  these  conditions,  an  account  of 
abnormal  modifications  of  the  heart-sounds  and 
cardiac  murmurs  will  conclude  this  chapter. 

Enlargement  of  (he  Heart. — Knlargement  of  the 
heart  may  be  slight,  moderate,  great,  or  very  great. 
these  terms  expressing  different  degrees  of  enlarge- 
ment with  sufficient  precision  for  clinical  purposes. 
In  cases  of  very  great  enlargement,  the  space  within 


216  THE    HEART. 

the  chest  which  the  heart  occupies  may  be  from  four 
to  five  times  larger  than  in  health.  The  situation 
of  the  base  of  the  heart  remains  but  little,  or  not  at 
all,  changed  in  cases  of  enlargement;  the  increased 
space  which  the  heart  occupies  is  therefore  down- 
ward. The  increased  space  extends  much  more  to 
the  left  than  to  the  right;  the  left  border  of  the 
heart,  in  proportion  to  the  enlargement,  is  carried 
beyond  the  mammary  line  on  the  left  side,  whereas, 
the  right  border  is  carried  comparatively  but  little 
beyond  the  normal  right  lateral  boundary  of  the 
prtecordia  even  when  the  enlargement  is  very  great. 
The  superficial  cardiac  space  is  enlarged  in  propor- 
tion to  the  enlargement  of  the  heart;  the  organ 
pushes  to  the  left  the  receding  anterior  border  of  the 
upper  lobe  of  the  left  lung,  and  is  proportionately 
in  contact,  uncovered  of  lung,  with  the  walls  of  the 
chest.  The  apex  of  the  heart  is  lowered  in  propor- 
tion to  the  enlargement,  and  it  is  carried  more  or 
less  to  the  left  of  its  normal  situation.  It  may  be 
lowered  to  the  sixth,  seventh,  eighth,  or  ninth  inter- 
costal space.  The  enlargement  of  the  heart  is  rarely 
equal  in  all  its  parts.  The  ventricular  enlargement 
may  be  entirely  or  chiefly  of  either  the  right  or  the 
left  ventricle.  Enlargement  of  the  right  ventricle 
tends  to  carry  the  right  side  of  the  heart  more  to  the 
right  than  when  the  left  ventricle  is  enlarged.  The 
situation  of  the  apex  is  also  affected  by  the  parts  of 
the  heart  in  which  the  enlargement  predominates. 
The  apex  is  carried  further  to  the  left  of  its  normal 
situation,  other  things  being  equal,  when  the  en- 
largement predominates  on  the  right  side  of  the 
heart;  and  it  is  lowered  without  being  carried  far 


CONDITIONS    OF    HEART    IN    DISEASE.       217 

to  the  left  when  the  enlargement  of  the  left  ventricle 
predominates.  The  apex  of  the  organ  in  cases  of 
considerable  or  of  great  enlargement  becomes 
changed  in  form;  it  is  rounded  or  blunted.  This 
change  is  most  marked  when  enlargement  of  the 
right  ventricle  predominates.  All  these  points  are 
of  importance  with  reference  to  the  comprehension 
of  the  physical  signs  of  enlargement  of  the  heart. 

Enlargement  of  the  heart  may  be  entirely  due 
either  to  hypertrophy  or  to  dilatation  (simple  hyper- 
trophy and  simple  dilatation).  If,  however,  the 
enlargement  be  sufficient  to  occasion  notable  dis- 
turbance  of  the  circulation,  both  these  forms  of 
enlargement  are  combined,  but,  as  a  rule,  one  or 
the  other  form  predominating,  so  that,  of  the  cases 
of  diseases  of  the  heart  which  come  under  medical 
treatment,  the  majority  are  cases  of  either  enlarge- 
ment with  predominant  hypertrophy  or  enlargement 
with  predominant  dilatation. 

These  widely  different  physical  conditions  are 
concerned  especially  in  the  abnormal  impulses  and 
modifications  of  the  apex-beat,  as  well  as,  also,  the 
heart-sounds. 

Abnormal  Impulses  of  the  Heart,  and  Modifications  of 
the  Apex-beat. — The  abnormal  situation  of  the  apex 
of  the  heart  when  enlarged  lias  been  stated.  Gen- 
erally the  situation  is  determinable  by  the  apex-beat. 
It  has  been  seen  that  in  health  the  beat  is  sometimes 
not  appreciable  by  the  touch,  owing  to  the  thickness 
of  tin'  soft  parts, and  the  conformation  of  the  thorax, 
ami,  for  these  reasons,  the  force  of  the  beat  varies 
much  in  different  healthy  persons.  Exclusive  of 
normal  variations,  the  beat  i>  generally  strong  and 

19 


218  THE    HEART. 

prolonged  in  proportion  as  the  heart  is  enlarged  by 
hypertrophy.  There  are  exceptions  to  this  state- 
ment, which  are  to  be  explained  by  the  altered  form 
of  the  apex;  when  it  loses  its  pointed  form  it  does 
not  so  readily  come  into  contact  with  the  walls  of 
the  chest  in  an  intercostal  space,  and,  hence,  the  beat 
may  be  weak  although  the  ventricular  systole  be 
abnormally  strong.  On  the  other  hand,  the  apex- 
beat  is  weakened  by  dilatation,  and  it  may  be  want- 
ing as  a  result  of  diminished  strength  of  the  systole 
of  the  ventricles.  The  apex-beat  is  also  abnormally 
weak  in  fatty  degeneration  and  softening  of  the 
heart,  as  well  as  in  functional  debility  of  the  organ 
incident  to  other  diseases  than  those  of  the  heart. 

If  there  be  considerable  or  great  enlargement,  the 
heart  being  in  contact  with  the  walls  of  the  chest 
over  a  larger  area  than  in  health,  impulses  other 
than  the  apex-beat  are  generally  apparent  to  the  eye 
and  touch.  Not  infrequently  impulses  are  appre- 
ciable in  each  intercostal  space  between  the  situation 
of  the  apex  and  the  base  of  the  heart.  These  ab- 
normal impulses  are  felt  to  be  strong  in  proportion 
as  the  enlargement  is  due  to  hypertrophy,  and  weak 
in  proportion  as  dilatation  predominates.  Enlarge- 
ment seated  in  the  right  ventricle  causes  an  impulse 
in  the  epigastrium  which  is  strong  or  weak  in  pro- 
portion as  hypertrophy  or  dilatation  predominates. 
Cardiac  impulses  are  felt  and  seen  in  abnormal  situ- 
ations when  the  heart  is  removed  from  its  normal 
situation  by  the  pressure  of  an  aneurism,  or  other 
tumor,  by  pleuritic  effusion,  hydroperitoneum,  etc. 
The  error  of  mistaking  for  a  cardiac  impulse  the 
pulsation  of  an  aneurismal  tumor  is  to  be  avoided. 


CONDITIONS    OF    HEART    IN    DISEASE.      219 

Another  error  is  to  be  avoided,  namely,  mistaking 
abnormal  impulses  due  to  the  heart  being  uncovered 
of  lung,  from  shrinking  of  the  latter  in  certain  pul- 
monary affections,  for  impulses  denoting  enlarge- 
ment of  the  heart.  In  cases  of  enlargement  by 
hypertrophy,  a  heaving  movement  of  the  whole 
praecordia  is  sometimes  felt  when  the  hand  is  applied 
to  the  chest.  A  violent  shock  is  sometimes  felt  by 
the  hand  applied  to  the  prsecordia,  but  without  a 
sense  of  increased  muscular  power,  in  cases  of  purely 
functional  disorders  of  the  heart. 

Valvular  Lesions. — The  lesions  affecting  the  valves 
of  the  heart  are  of  a  varied  character,  for  an  account 
of  which  the  student  is  referred  to  treatises  on  car- 
diac diseases,  or  on  pathological  anatomy.  It  suffices 
here  to  consider  that,  with  reference  to  physical  signs 
and  pathological  effects,  they  may  be  distributed  into 
three  groups,  as  follows  :  1st,  lesions  which  diminish 
more  or  less  the  size  of  the  orifices,  or  obstructive 
lesions  ;  2d,  lesions  which  render  the  valves  more  or 
less  incompetent  and  permit  regurgitation,  or  re- 
gurgitative  lesions;  and,  3d,  lesions  which  roughen 
the  surfaces  over  which  the  blood  moves  without 
occasioning  either  obstruction  or  regurgitation.  The 
latter  may  be  distinguished  as  innocuous  lesions, 
giving  rise  to  no  pathological  effects  although  repre- 
sented by  cardiac  murmurs. 

It  is  to  be  borne  in  mind  that  in  the  great  majority 
of  cases  valvular  lesions  are  seated  in  the  left  side  of 
the  heart,  that  is,  they  are  either  mitral  or  aortic. 
Tricuspid  and  pulmonic  lesions  are  comparatively 
rare,  and  they  are  generally  congenital.  Nol  infre- 
quently mitral  and  aortic  lesions  coexist,  and  there 


220  THE     HEART. 

may  be  coexisting  lesions  at  all  the  orifices  of  the 
heart. 

Valvular  lesions  are  represented  by  cardiac  mur- 
murs. By  means  of  the  murmurs  the  existence  of 
lesions  is  known,  their  situation  at  the  different 
orifices  may  be  ascertained,  and,  generally,  it  is 
practicable  to  determine  whether  they  occasion  ob- 
struction or  regurgitation,  or  both.  These  several 
points  of  inquiry  will  be  considered  presently  under 
the  heading  Cardiac  Murmurs,  and  in  connection 
with  the  lesions  of  the  different  valves  respectively 
in  the  next  chapter. 

Roughness  of  the  Pericardial  Surfaces. — In  place  of 
the  smoothness  of  the  pericardial  surfaces  in  health, 
which  permits  their  movements  upon  each  other 
noiselessly,  the  presence  of  the  inflammatory  product 
lymph,  and,  in  some  rare  instances,  morbid  growths, 
occasion  an  adventitious  sound  or  murmurs,  which 
will  be  noticed  in  connection  with  other  murmurs, 
and  as  entering  into  the  physical  diagnosis  of  peri- 
carditis. 

Liquid  within  the  Pericardial  Sac. — More  or  less 
liquid  transudes  into  the  pericardial  sac  in  cases  of 
general  dropsy  or  anasarca,  but  rarely  in  very  large 
quantity.  Liquid  effusion  occurs  in  acute  peri- 
carditis, and  in  this  affection  the  sac  may  become 
filled  with  liquid.  In  some  cases  of  chronic  peri- 
carditis the  sac  is  greatly  dilated  by  liquid,  the 
quantity  amounting  to  four  pounds,  or  even  more. 

When  the  pericardial  sac  is  filled  with  liquid, 
without  being  dilated,  it  forms  a  pyriform  tumor 
within  the  chest,  the  base  of  which  is  at  the  sixth  or 
seventh  intercostal  space;  the  apex  rises  nearly  to 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.      221 

the  sternal  notch  ;  the  left  lateral  border  is  consider- 
ably beyond  the  nipple,  and  the  right  lateral  border 
is  more  or  less  beyond  the  right  margin  of  the  prae- 
cordia.  The  anterior  portion  of  the  filled  pericar- 
dium is  mostly  uncovered  of  lung  and  in  contact 
with  the  walls  of  the  chest.  Within  this  area  there 
is  either  notable  dulness  or  flatness  on  percussion, 
together  with  absence  of  respiratory  murmur  and  of 
vocal  resonance.  By  means  of  these  signs,  the 
boundaries  of  the  pyriform  tumor  may  be  readily 
delineated  on  the  surface  of  the  chest.  The  differ- 
ence in  form  and  situation  of  the  area  of  dulness  or 
flatness  on  percussion  in  cases  of  large  pericardial 
effusion,  from  the  area  in  cases  of  enlargement  of  the 
heart  (vide  page  216),  is  to  be  noted  and  borne  in 
mind  with  reference  to  the  differential  diagnosis. 

When  the  pericardial  sac  is  partially  filled  with 
liquid,  the  same  signs  are  present,  but  within  an 
area  of  less  extent,  and  the  configuration  of  the 
pyriform  tumor  is  wanting. 

In  cases  of  chronic  pericarditis  with  a  large  accu- 
mulation of  liquid,  the  pericardial  sac  is  dilated  so 
that  its  lateral  boundaries  may  extend  nearly  to  the 
axillary  and  infra-axillary  regions.  Under  these 
circumstances,  flatness  on  percussion,  absence  of 
respiratory  murmur  and  of  vocal  resonance,  are 
present  over  the  greater  part  of  the  anterior  aspect 
of  the  chest. 

Abnormal  Modifications  of  the  Heart-sounds. 

In  order  to  appreciate  the  abnormal  modifications 

of  the  heart-sounds,  their  normal  characters  are  to 
he  kept   in   mind  (vide  page  209),  and  the  student 


222  THE    HEART. 

must  be  practically  familiar  with  them.  The  modi- 
fications relate  to  the  three  components  of  the 
systolic  sound,  and  to  the  two  components  of  the 
diastolic  sound,  collectively  and  separately. 

The  sound  of  impulsion,  as  heard  over  the  apex, 
is  intensified  in  hypertrophy  of  the  heart.  This 
sound  is  not  only  notably  loud,  but  prolonged,  and 
its  booming  quality  is  marked.  It  sometimes  has  a 
ringing  tone,  called  tinnitus.  The  systolic  valvular 
sounds,  namely,  the  mitral  and  the  tricuspid,  are 
also  more  or  less  increased  in  intensity.  The  in- 
creased intensity  of  either  the  mitral  or  the  tricuspid 
valvular  sound,  separately  denotes  that  the  hyper- 
trophy is  seated  especially  in  either  the  left  or  the 
right  ventricle. 

In  some  cases  of  violent  palpitation  the  systolic 
sounds  are  notably  intensified,  the  sound  of  impul- 
sion being  comparatively  weak.  I  suppose  the 
explanation  to  be  as  follows  :  the  ventricles  contract 
with  a  kind  of  spasmodic  action  upon  a  small  quan- 
tity of  blood;  and,  under  these  circumstances,  the 
auriculo-ventricular  valves,  not  being  floated  out  as 
they  are  when  the  ventricles  are  well  filled,  expand 
with  force  in  the  ventricular  systole,  instead  of  being 
merely  made  tense  as  in  health.  Hence,  the  valvular 
sounds  are  intensified,  while  the  sound  of  impulsion 
may  be  feeble  or  wanting.  The  sound  of  impulsion 
over  the  apex  is  weakened  or  lost  as  an  effect  of 
those  affections  of  the  heart  which  diminish  the 
power  of  the  ventricular  systole.  These  affections 
are  enlargement  from  dilatation,  atrophy,  fatty  de- 
generation, myocarditis,  obstruction  of  the  coronary 
arteries,  and  softening.    The  systolic  valvular  sounds 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.       223 

are  also  more  or  less  weakened,  but  in  a  less  degree 
than  the  sound  of  impulsion.  The  loss  of  the  sound 
of  impulsion  over  the  apex  renders  the  so-called  first 
or  systolic  sound  of  the  heart  short  and  valvular  in 
qualit}\ 

Liquid  effusion  within  the  pericardium  renders  the 
sound  of  impulsion  over  the  apex  more  or  less  weak. 
If  the  liquid  effusion  be  large,  only  the  systolic  val- 
vular sounds,  namely,  the  mitral  and  tricuspid,  are 
appreciable.  Diminished  power  of  the  heart's  action 
from  other  than  cardiac  diseases,  involves  weakness 
of  all  the  heart-sounds,  but  more  especially  of  the 
sound  of  impulsion. 

Abnormal  modifications  of  the  diastolic  sound  re- 
late to  the  aortic  and  pulmonic  sounds  considered 
separately.  Bearing  in  mind  the  mode  of  interro- 
gating the  aortic  and  the  pulmonic  orifice  with 
reference  to  the  valvular  sound  derived  from  each 
independently  of  the  other  (vide  page  213),  a  com- 
parison of  the  two  sounds  in  diseases  of  the  heart 
affords  often  useful  information.  Whenever,  from 
mitral  obstructive  or  regurgitant  lesions,  or  both 
combined,  the  quantity  of  blood  propelled  by  the 
left  ventricle  into  the  aorta  is  diminished,  the  recoil 
of  the  arterial  coats,  after  the  ventricular  systole,  is 
lessened  ;  consequently,  the  aortic  segments  expand 
with  less  force,  and  the  aortic  sound  is  weakened. 
Diminished  intensity  of  the  aortic  sound  thus  repre- 
sents an  abnormal  diminution  of  the  quantity  of 
blood  propelled  into  the  s}*eteniic  arteries  by  the 
systole  of  the  left  ventricle,  and  this  diminished  in- 
tensity of  sound  is,  in  a  measure,  a  criterion  of  the 
amount  of  mitral  obstruction  or  mitral  regurgitation, 


224  THE    HEART. 

or  both  combined,  hi  some  cases  of  great  obstruc- 
tion or  regurgitation,  the  aortic  sound  is  completely 
suppressed.  How  is  weakening  of  this  sound  to  be 
determined  and  measured?  By  comparison  with 
the  pulmonic  sound.  Now,  as  will  presently  appear, 
the  pulmonic  sound  is  often  intensified  when  the 
aortic  sound  is  weakened.  Hence,  the  former  is  not 
an  accurate  standard  for  this  comparison ;  but  it 
suffices  for  an  approximation  to  accuracy.  In  cases 
of  hypertrophy  of  the  left  ventricle  without  obstruc- 
tive or  regurgitant  valvular  lesions,  the  aortic  sound 
is  abnormally  intensified.  These  cases  occur  chiefly 
in  connection  with  fibroid  or  atrophic  lesions  of  the 
kidneys.  Intensification  of  the  aortic  sound  may  be 
due  to  increased  tension  of  the  systemic  arteries 
without  cardiac  hypertrophy. 

A  simpler  cause  of  weakening  or  suppression  of  the 
aortic  sound,  is  damage  from  lesions  of  the  aortic 
valve.  In  proportion  as  the  function  of  this  valve  is 
impaired  by  lesions,  the  intensity  of  the  sound  is 
diminished,  and  if  the  function  of  the  valve  be  lost, 
the  sound  is  wanting.  In  these  cases,  the  pulmonic 
sound  being  but  little  or  not  at  all  affected,  it  is  an 
accurate  standard  for  the  comparison. 

The  pulmonic  sound  is  weakened  in  the  rare  in- 
stances of  lesions  affecting  the  pulmonic  valve.  This 
sound  is  oftener  intensified  than  weakened.  It  is 
notably  intensified  when  the  right  ventricle  is  hyper- 
trophied,  and  especially  when  this  hypertrophy  is 
associated  with  dilatation  of  the  left  auricle  resulting 
from  mitral  obstruction  or  regurgitation.  These 
lesions  weakening,  as  has  just  been  seen,  the  aortic 
sound,  the  contrast  between  the  aortic  and  the  pul- 


ABNORMAL    MODIFICATIONS    OF    SOUNDS.       225 

monic  sound  in  some  cases  of  mitral  lesions  is  very 
marked.  The  pulmonic  sound  is  sometimes  loud, 
while  the  aortic  sound  is  suppressed. 

Increased  tension  of  the  pulmonary  arterial  system 
may  increase  the  intensity  of  the  pulmonic  sound, 
irrespective  of  hypertrophy  of  the  right  ventricle. 
This  increased  tension  is  incident  to  certain  pul- 
monary affections — pneumonia,  pleurisy,  asthma, 
etc.  This  sound  is  also  intensified  in  cases  of  func- 
tional palpitation  and  excitation  of  the  heart  by 
exercise  and  emotional  excitement. 

In  comparing  the  aortic  and  the  pulmonic  sound 
in  disease,  as  in  health,  it  is  to  be  assumed  that  the 
anatomical  relations  of  the  aortic  and  the  pulmonary 
artery  to  the  second  intercostal  space  on  either  side, 
close  to  the  sternum,  are  not  materially  altered,  and 
that  the  lungs  are  free  from  lesions  in  consequence 
of  which  the  conduction  of  the  sound  on  either  side 
is  abnormal. 

Returning  to  the  systolic  group  of  sounds,  the 
mitral  and  the  tricuspid  sound  may  be  studied  sepa- 
rately. With  the  stethoscope  applied  at  or  a  little 
to  the  left  of  the  apex,  the  valvular  sound  which  is 
heard  is  derived  from  the  mitral  valve.  On  the 
other  hand,  if  the  stethoscope  be  applied  at  or  near 
the  right  lower  border  of  the  heart,  the  valvular  sound 
is  derived  from  the  tricuspid  valve.  Notable  weak- 
ness or  suppression  of  the  mitral  sound,  as  compared 
with  the  tricuspid,  represents  impairment  of  the 
function  of  the  mitral  valve,  and,  per  contra,  notable 
weakness  or  suppression  of  the  tricuspid  sound  de- 
notes impairment  of  the  function  of  the  tricuspid 
valve.      Allowance  in  this  comparison  is  to  be  made 


226  THE    HEART. 

for  a  normal  disparity,  the  mitral  sound  being  louder 
than  the  tricuspid  in  health. 

Reduplication  of  Heart-sounds. — The  sounds  of  the 
heart  are  said  to  be  reduplicated  when  either  the 
systolic  or  the  diastolic  sounds  are  repeated,  or  when 
both  occur  twice  before  the  long  pause  or  interval. 
Considering  the  heart-sounds  as  two-fold,  that  is, 
systolic  and  diastolic,  and  as  represented  by  the 
whispered  words  Lub-dup,  reduplication  of  the  sys- 
tolic sound  is  expressed  by  Lublub-dup,  of  the 
diastolic  by  Lub-dupdup,  and  of  both  by  Lublub- 
dupdup. 

Clinically,  reduplication  of  the  diastolic  is  ob- 
served much  more  frequently  than  reduplication  of 
the  systolic  sound.  In  other  words,  the  pulmonic 
and  aortic  sounds,  instead  of  being  synchronous, 
occur  in  succession.  This  may  occur  when  the  sys- 
tolic sounds  occur  synchronously.  The  explanation 
is,  that  from  increased  tension  of  either  the  systemic 
or  the  pulmonic  arteries  (oftener  the  latter),  the 
recoil  of  the  arterial  coats  after  the  systole,  and  the 
extension  of  the  sigmoid  valves,  take  place,  in  one 
artery  sooner  than  in  the  other.  If  both  the  systolic 
and  the  diastolic  sounds  be  reduplicated,  the  explana- 
tion which  seems  most  rational  is,  that  the  two  ven- 
tricles contract,  not  in  exact  unison,  but  that  one 
contracts  a  little  before  the  other.  In  systolic  redu- 
plication the  mitral  and  the  tricuspid  sounds  occur 
in  succession  instead  of  occurring  synchronously. 
The  sound  of  impulsion  is  not  reduplicated. 

There  is  a  form  of  functional  disorder  which  may 
be  confounded  with  reduplication  of  both  sounds  of 
the  heart.     In  this   disorder,  with  every  alternate 


CARDIAC    MURMURS.  "J27 

revolution  of  the  heart,  the  sounds  are  weak,  and 
the  ventricular  systole  is  not  represented  by  a  radial 
pulse,  the  force  of  the  contraction  of  the  ventricle 
being  insufficient  to  cause  an  appreciable  pulsation 
in  the  remote  arteries;  hence,  the  heart-sounds 
occur  twice  for  each  pulse  at  the  wrist.  Under  these 
circumstances,  however,  the  carotid  pulse  may  gen- 
erally, if  not  always,  be  felt  with  the  weak,  as  well 
as  with  the  stronger,  ventricular  contraction,  and  in 
this  way  the  error  of  confounding  the  disorder  with 
reduplication  may  be  avoided. 

Keduplication  of  the  heart-sounds  may  occur  in 
connection  with  cardiac  lesions,  or  there  may  be  no 
evidence  of  any  organic  affection.  In  the  latter  case 
the  anomaly  falls  properly  among  the  varied  forms 
of  functional  disorder  of  the  heart.  Whether,  or 
not,  it  be  connected  with  lesions,  it  has  no  important 
pathological  significance.  It  is  usually  of  temporary 
duration. 

Cardiac  Murmurs. 

All  adventitious  abnormal  sounds  which  are  added 
to  the  heart-sounds,  are  embraced  by  the  term  cardiac 
murmurs.  Let  it  be  borne  in  mind  that,  conven- 
tionally, the  murmurs  are  never  abnormal  modifica- 
tions of  the  heart-sounds,  but  always  newly  produced 
sounds,  and  they  always  represent  morbid  conditions 
of  either  the  heart  or  the  blood.  When  due  to 
morbid  conditions  of  the  blood,  they  are  called  in- 
organic, anaemic,  or  hffimic  murmurs,  and  when  tiny 
represent  valvular  lesions  or  changes  within  the 
heart,  they  an'  distinguished  as  organic  murmurs. 

The  murmurs  may  be  disi  ributed  into  three  groups 


228  THE    HEART. 

after  differences  in  quality,  namely:  1st,  soft;  2d, 
rough;  and,  3d,  musical  murmurs.  The  soft  mur- 
murs resemble  the  sound  produced  by  air  from  the 
nozzle  of  a  pair  of  bellows,  and,  hence,  are  often 
called  bellows  murmurs.  Murmurs  are  said  to  be 
rough  when  their  qualities  may  be  expressed  by  such 
terms  as  rasping,  grating,  creaking,  croaking,  etc. 
They  are  called  musical  when  the  sound  is  a  musical 
note.  The  bellows  murmurs  are  the  most  frequent, 
and  the  musical  are  more  rare  than  the  rough  mur- 
murs. The  quality  of  a  murmur  does  not  in  general 
invest  it  with  any  special  pathological  or  diagnostic 
significance.  The  murmurs  vary  in  pitch,  being 
either  relatively  high  or  low.  The  variations  in 
pitch  are  useful  in  aiding  to  discriminate  different 
coexisting  murmurs. 

This  account  of  murmurs  applies  to  those  produced 
at  the  orifices  or  within  the  cavities  of  the  heart. 
They  are  distinguished  as  endocardial  murmurs. 
Adventitious  sounds  are,  however,  produced  upon 
the  external  surface  of  the  heart.  These  constitute 
exocardial,  pericardial,  or  friction  murmurs. 

Endocardial  murmurs  are  produced  by  blood- 
currents  pursuing  either  a  normal  or  an  abnormal 
direction.  With  a  familiar  knowledge  of  these  cur- 
rents, and  of  their  relations  with  the  heart-sounds, 
the  several  endocardial  murmurs  are  very  easily 
understood,  as  regards  points  involved  in  their  dif- 
ferentiation from  each  other.  The  student  is,  there- 
fore, advised  first  to  become  acquainted  with  the 
blood-currents  in  health  and  in  disease.  Directing 
the  attention  to  the  left  side  of  the  heart,  there  are 
two  normal  blood-currents,  namely,  the  current  from 


CARDIAC    MURMURS. 


229 


the  left  auricle  to  the  left  ventricle,  and  the  current 
from  the  left  ventricle  into  the  aorta.  These  may 
1)0  distinguished  as  the  direct  currents.  The  first  is 
the  mitral  direct  current,  and  the  second  is  the  aortic 
direct  current.  Two  abnormal  currents  may  occur 
in  the  left  side  of  the  heart.  These  currents  can 
only  take  place  when  the  valves  are  rendered  incom- 
petent by  lesions.     The  incompetency  of  the  valves 

Fro.  1.°,. 


no  repreaenting|the  Abnormal  Blood-currents. 

Plain  arrowa  represent  currents  in  ri^ht  side  "f  heart.    Dotted  arrows  represent 
currents  in  left  side  of  heart. 


allows  of  regurgitation,  and  these  abnormal  currents 
may  be  distinguished  as  the  regurgitant  currents. 
One  of  these  is  a  current  backward  from  the  left 
ventricle  into  the  left  auricle,  owing  to  incompetency 
of  the  mitral  valve;  this  is  the  mitral  regurgitant 
current.  The  other  is  a  current  backwards  from 
the  aorta  into  the  left  ventricle,  arising  from  incom- 

20 


230 


THE    HEART. 


petency  of  the  aortic  valve;  this  is  the  aortic  regur- 
gitant current.     (Figs.  13  and  14.) 

What  are  the  relations  of  the  four  currents  in  the 
left  side  of  the  heart  with  the  heart-sounds  ?  The 
mitral  direct  current  takes  place  when  the  auricles 

Fig.  14. 


Diagram  representing  the  Normal  Blood-currents. 

Plain  arrows  represent  currents  in  right  side  of  heart.     Dotted  arrows  represent 

currents  in  left  side  of  heart. 

contract.  The  contraction  of  the  auricles  precedes 
the  ventricular  systole.  The  ventricular  systole  is 
synchronous  with  the  systolic  sounds  of  the  heart. 
The  mitral  direct  current,  therefore,  takes  place  just 
before  these  sounds.  It  begins  after  the  diastolic 
sounds,  and  continues  until  it  is  suddenly  and  com- 
pletely arrested  by  the  contraction  of  the  ventricle. 
It  is,  therefore,  presystolic.  It  is  obvious  that  the 
current  cannot  continue  during  the  ventricular  con- 
traction, that  is,  when  the  first  systolic  sounds  of  the 
heart  are  produced.     The  mitral  regurgitant  current 


CARDIAC    MURMURS.  231 

is  caused  by  the  contraction  of  the  ventricle  ;  the 
current,  therefore,  must  take  place  with  the  systolic 
sounds  of  the  heart.  The  aortic  direct  current,  being 
caused  by  the  contraction  of  the  left  ventricle,  takes 
place  with  the  systolic  sounds  of  the  heart.  It  is, 
therefore,  coincident  with  the  mitral  regurgitant 
current.  The  aortic  regurgitant  current  is  caused 
by  the  recoil  of  the  arterial  coats  upon  the  column 
of  blood  within  the  aorta  directly  after  the  ven- 
tricular systole,  and  as  this  recoil  causes  the  diastolic 
aortic  sound  of  the  heart,  the  current  and  this  sound 
must  be  coincident. 

Recapitulating  the  relations  of  the  four  currents 
with  the  heart-sounds,  the  aortic  direct  and  the 
mitral  regurgitant  take  place  with  the  systolic  sounds 
— they  are  systolic  currents.  The  mitral  direct  cur- 
rent precedes  the  systolic  sounds — it  is  presystolic ; 
and  the  aortic  regurgitant  current  takes  place  with 
the  diastolic  sound — it  is  diastolic. 

Analogous  blood-currents  take  place  in  the  right 
side  of  the  heart,  and  have  corresponding  relations 
with  the  heart-sounds.  These  currents  are  the  tri- 
cuspid direct,  the  tricuspid  regurgitant,  the  pulmonic 
direct,  and  the  pulmonic  regurgitant.  The  pulmonic 
regurgitant  is  exceedingly  rare  in  consequence  of  the 
infrequency  of  pulmonic  lesions;  but  the  tricuspid 
regurgitant  is  not  uncommon,  and  occurs  without 
valvular  lesions  or  enlargement  of  the  heart  when 
the  right  ventricle  is  distended  with  blood,  consti- 
tuting what  has  been  called  the  "safety  valve  func- 
tion  "  of  the  tricuspid  orifice. 

Organic  endocardia]  murmurs  are  produced  by 
tin-  foregoing  direci  and  regurgitant  blood-currents, 


232  THE    HEART. 

and  they  are  designated  by  the  same  names,  that  is, 
they  are  either  direct  or  regurgitant.  Thus,  there 
are  produced  in  the  left  side  of  the  heart — the  side 
in  which  valvular  lesions  are  seated  in  the  great 
majority  of  cases — a  mitral  direct  murmur,  a  mitral 
regurgitant  murmur,  an  aortic  direct  murmur,  and 
an  aortic  regurgitant  murmur.  In  the  right  side  of 
the  heart  there  may  be  produced  corresponding 
murmurs,  namely,  a  tricuspid  direct,  a  tricuspid 
regurgitant,  a  pulmonic  direct,  and  a  pulmonic 
regurgitant.  It  remains  to  point  out  the  means  of 
differentiating  these  several  murmurs  aside  from 
their  relations  with  the  heart-sounds. 

31iiral  Direct  or  Presystolic  Murmur. — This  murmur 
begins  after  the  diastolic  sounds  and  ends  abruptly 
with  the  systolic  sounds.  Almost  invariably,  this 
murmur  is  rough  in  quality ;  occasionally,  it  is  a  soft 
bellows  murmur.  When  rough,  it  is  often  quite 
loud.  The  rough  quality  is  peculiar  ;  it  is  suggestive 
of  vibration,  and  may  be  imitated  by  causing  the 
lips  or  the  tongue  to  vibrate  with  the  breath  in  ex- 
piration. I  state  the  mechanism  of  this  murmur, 
inasmuch  as  the  explanation  is  original  with  me,  and 
has  not  been  as  yet  generally  accepted.  It  is  caused 
by  the  vibrations  of  the  mitral  curtains,  and  takes 
place  when  these  curtains  are  united  at  their  sides, 
leaving  a  narrow  buttonhole-like  orifice  through 
which  the  mitral  direct  current  of  blood  flows. 
Throwing  the  lips  into  vibration  with  the  breath, 
represents  not  only  the  characteristic  quality  of  the 
murmur,  but  the  mode  of  its  production.  The 
physical  conditions  which  are  requisite  generally  for 
its  production  are  a  narrowed  mitral  orifice,  and 


CARDIAC    MURMURS.  233 

flaccidity  of  the  mitral  curtains.  The  latter  of  these 
conditions  does  not  always  exist  in  cases  of  mitral 
obstructive  lesions,  and,  hence,  the  murmur  by  no 
means  always  accompanies  these  lesions.  When  it 
is  considered  how  loud  a  blubbering  sound  may  be 
produced  by  the  vibration  of  the  lips  with  a  feeble 
current  of  air,  it  is  not  difficult  to  understand  that 
an  intense  murmur  may  be  caused  by  a  current  of 
blood  propelled  by  the  comparatively  weak  contrac- 
tion of  the  auricle.  This  murmur  may  be  produced 
artificially,  and  the  mechanism  of  its  production 
demonstrated  in  the  following  manner:  Take  a  small 
India-rubber  bag  with  thin  walls — such  as  that  which, 
when  inflated,  makes  a  balloon  for  children;  attach 
the  opening  to  the  efferent  tube  of  a  Davidson's 
syringe;  make  a  small  orifice  opposite  to  the  at- 
tached opening  of  the  bag;  immerse  the  bag  in  a 
basin  of  water,  and  then  force  a  current  of  water 
into  the  bag.  With  a  binaural  stethoscope,  the  pec- 
toral extremity  applied  lightly  to  the  bag,  a  murmur 
caused  by  the  flow  of  water  from  the  bag  into  the 
basin,  is  heard,  resembling  as  closely  as  possible  the 
usual  presystolic  murmur. 

Peter  states  that  the  production  of  a  mitral  pre- 
systolic murmur  requires  hypertrophy  of  the  left 
auricle.1  This  may  be  doubted,  in  view  of  the  fact 
to  be  stated  in  the  uexl  paragraph.  Hypertrophy  of 
the  auricle,  however,  accompanies  the  lesion  which 
the  murmur  represents,  when  the  murmur  is  organic 

A  mitral  direct  murmur  may  be  produced  without 
mitral    lesion-,  lie-   murmur  having  the  same  char- 

1  Traitf  dee  Maladies  du  Cceur,  Pt 

20* 


234  THE    HEART. 

acteristic  quality  as  when  lesions  exist,  and  being 
also  quite  loud.  This  fact,  based  on  clinical  proof, 
was  stated  by  me  many  years  since,  together  with 
the  explanation.  The  murmur  occurs  when  there 
are  aortic  lesions  which  permit  regurgitation.  Under 
these  circumstances,  at  the  time  when  the  auricular 
contraction  takes  place,  the  left  ventricle  is  already 
filled  with  blood,  the  mitral  curtains  are  floated  out 
so  as  to  be  in  contact  with  each  other,  and  the  mitral 
direct  current  passing  between  the  curtains  throws 
them  into  vibration  precisely  as  when  the  orifice  is 
narrowed.  The  vibration  of  the  lips  when  lightly 
in  contact,  caused  by  the  expired  breath,  illustrates 
the  manner  in  which  a  mitral  direct  murmur  takes 
place  without  mitral  lesions.  The  murmur  thus 
occurring  without  mitral  lesions  is  not  constant;  it 
is  now  present  and  now  absent,  depending,  as  it 
does,  on  the  quantity  of  blood  within  the  left  ven- 
tricle at  the  time  of  the  contraction  of  the  auricle. 
It  follows  from  what  has  just  been  stated,  that  a 
mitral  direct  murmur  is  not  always  a  sign  of  mitral 
obstructive  lesions  when  there  is  free  aortic  regur- 
gitation. 

This  murmur  is  limited  to  a  circumscribed  space 
around  the  apex  of  the  heart.  However  loud  the 
murmur  may  be  in  this  situation,  it  is  lost  within  a 
short  distance  from  the  apex.1 

It  is  proper  to  state  that  some  observers  do  not 
attribute  a  presystolic  murmur  to  the  mitral  direct 
current.  Donaldson,  Learning,  and  others,  suppose  it 
to  be,  in  fact,  a  mitral  systolic  murmur,  the  murmur 

1  Professor  Janeway  states  that  in  rare  instances  he  has  heard 
this  murmur  over  the  lower  part  of  the  scapula. 


CARDIAC    MURMURS.  235 

reaching  the  ear  before  the  systolic  sounds  are  heard. 
The  occurrence  of  this  murmur  in  connection  with 
aortic  lesions,  the  mitral  valves  being  sound,  Keyt 
explains  by  supposing  that  the  murmur  may  be  pro- 
duced at  the  aortic  orifice,  the  murmur  being  heard 
before  the  systolic  sounds.  There  is,  however,  a 
very  general  agreement  that  the  murmur  is  correctly 
called  a  mitral  direct  murmur. 

A  mitral  direct  murmur  is  never  due  to  a  morbid 
condition  of  the  blood.  Although  it  occurs  without 
mitral  lesions,  yet,  inasmuch  as  its  occurrence  then 
requires  the  existence  of  aortic  regurgitant  lesions, 
it  cannot  be  said  to  be  an  inorganic  murmur. 

A  mitral  direct  murmur,  as  has  been  stated,  does 
not  always  accompany  mitral  lesions.  If  the  mitral 
curtains  are  fixed  or  made  rigid  by  calcification,  so 
that  vibration  with  the  mitral  direct  current  of  blood 
dues  not  take  place,  cither  the  murmur  is  wanting, 
or  its  usual  characteristic  quality  is  absent.  Feeble- 
ness of  the  auricular  contraction  from  dilatation  or 
over-distention  of  the  auricle  with  blood,  may  cause 
the  murmur  to  disappear.  Under  these  circum- 
stances the  murmur  may  be  sometimes  present  and 
at  other  times  absent.  Cardiac  vibration  or  thrill 
is  a  physical  sign  which  accompanies  often  a  well- 
marked  characteristic  presystolic  murmur,  but  this 
sign  may  occur  in  connection  with  other  valvular 
lesions.  The  thrill  is  presystolic  in  time  when  it 
accompanies  the  presystolic  murmur.  The  thrill  is 
systolic  when  it  accompanies  an  aortic  direct  <>r  a 
mitral  regurgitant  murmur,  and  diastolic  when  it 
accompanies  an  aortic  regurgitant  murmur. 


236  THE    HEART. 

Mitral  Diastolic  Murmur. — A  murmur  may  be 
produced  by  the  mitral  direct  current  of  blood  prior 
to  the  contraction  of  the  left  auricle ;  in  other  words, 
occurring  before  the  presystolic  murmur.  From  the 
latter  this  murmur  may  be  distinguished  as  a  mitral 
diastolic  murmur.  The  flow  of  blood  from  the 
auricle  into  the  ventricle  begins  directly  the  ven- 
tricular systole  ends.  This  may  be  said  to  be  a 
passive  current  until  the  auricle  contracts.  The 
contraction  of  the  auricle  makes  the  current  active. 
Now,  under  certain  organic  conditions,  the  passive 
current  produces  a  murmur  which,  in  point  of  time, 
is  diastolic,  that  is,  directly  following  the  diastolic 
sounds  of  the  heart.  The  murmur  occurs  at  the 
same  time  as  an  aortic  regurgitant  murmur.  From 
the  latter  it  is  to  be  discriminated  by  its  localization 
at  or  near  the  apex  of  the  heart,  and  by  the  absence 
of  a  diastolic  murmur  at  the  base.  It  may  precede 
the  characteristic  presystolic  murmur,  differing  from 
the  latter  in  quality,  or  the  diastolic  murmur,  with- 
out trie  characteristics  which  usually  belong  to  the 
presystolic  murmur,  may  continue  during  the  whole 
of  the  long  pause  of  the  heart. 

The  mitral  diastolic  murmur  (as  this  murmur  may 
be  called)  is  doubtless  rare,  but  less  so,  perhaps,  than 
may  be  supposed,  for  two  reasons:  first,  it  is  apt  to 
be  overlooked;  and,  second,  when  recognized  it  has 
been  customary  to  refer  it  to  the  aortic  orifice.  The 
frequency  of  the  murmur  and  the  particular  physical 
conditions  under  which  it  is  present,  are  to  be  de- 
termined by  further  clinical  study. 

Mitral  Regurgitant  Murmur — Mitral  Systolic  Non- 
regurgitant,  or  Intra-vcntricular  Murmur. — The  mitral 


CARDIAC    MURMURS.  237 

regurgitant  murmur,  synchronous  with  the  Byetolic 

sounds,  that  is,  a  systolic  murmur,  may  be  soft, 
rough,  or  musical  in  quality,  its  intensity  and  pitch 
being  variable.  Aside  from  its  relation  with  the 
systolic  heart-sounds,  it  is  distinguished  by  having 
its  maximum  of  intensity  at  or  near  the  situation  of 
the  apex-beat.  It  may  be  limited  to  a  circumscribed 
area,  and  if  heard  at  a  distance  from  the  apex  it  is 
best  transmitted  laterally  around  the  left  side  of  the 
chest,  on  the  line  of  the  apex.  It  is  often  heard  on 
the  posterior  aspect  of  the  chest  near  the  lower  angle 
of  the  left  scapula,  and  not  infrequently  in  the  cor- 
responding situation  on  the  right  side. 

A  murmur  with  the  systolic  sounds  of  the  heart 
heard  within  a  limited  area  at  the  apex,  may  be  due 
to  roughness  of  the  endocardial  membrane  without 
mitral  incompetency,  and,  consequently,  without  a 
mitral  regurgitant  current.  This  is  a  mitral  systolic 
non-regurgitant  murmur.  It  may,  also,  be  called  an 
intra-ventricular  murmur,  being  produced,  not  at 
the  mitral  orifice,  but  within  the  ventricle.  This 
murmur  cannot  always  be  discriminated  from  a 
feeble  mitral  regurgitant  murmur.  If,  however,  a 
mitral  murmur  be  conducted  laterally  for  some  dis- 
tance to  the  left  of  the  apex,  ami  if  it  be  heard  on 
the  back,  it  probably  denotes  mitral  regurgitation. 
A  mitral  systolic,  non-regurgitant,  or  intra-ventricu- 
lar murmur  is  the  murmur  presenl  in  endocarditis. 
It  may  be  caused,  as  has  been  demonstrated  by  my 
colleague,  I'rof.  Janeway,  by  a  tendinous  cord  ex- 
truding from  tlii'  inner  wall  on  our  side  to  the  oppo- 
site side  of  the  ventricular  cavity.  This  occurs  as  a 
congenita]   anomaly.     Aneurism  of  the  heart   may 


238  THE    HEART. 

be  so  situated  as  to  give  rise  to  a  murmur  simulating 
a  mitral  systolic  murmur.  Cardiac  aneurism,  how- 
ever, is  exceedingly  rare.  Aneurism  of  the  thoracic 
aorta  may  cause  a  murmur  which,  transmitted 
through  the  heart,  simulates  a  mitral  systolic 
murmur. 

The  impulse  of  the  apex  of  the  heart  against  the 
adjacent  portion  of  the  lung  sometimes  forces  the  air 
from  the  air-vesicles  sufficiently  to  give  rise  to  a 
blowing  sound  occurring  with  each  ventricular  sys- 
tole. This  is  liable  to  be  confounded  with  an  endo- 
cardial murmur.  Produced  in  the  way  just  stated, 
it  is  heard  only  during  the  act  of  inspiration,  and 
especially  at  the  end  of  this  act. 

A  mitral  systolic  murmur  is  rarely,  if  ever,  due  to 
an  abnormal  condition  of  the  blood,  without  any 
anatomical  change  in  the  valve  or  endocardial  mem- 
brane. Conditions  of  the  blood,  however,  which 
are  favorable  for  the  production  of  inorganic  mur- 
mur may  intensify  this  murmur  as  well  as  any  of  the 
organic  murmurs. 

It  has  been  conjectured  that  a  mitral  systolic  mur- 
mur may  be  produced  by  a  purely  functional  incom- 
petency of  the  mitral  valve,  permitting  a  mitral 
regurgitant  current,  no  actual  lesion  of  the  valve  or 
the  mitral  orifice  existing.  In  this  way  are  explained 
the  occurrence  of  a  mitral  systolic  murmur  and  its 
disappearance  after  a  remoter  duration,  without 
other  evidence  of  endocarditis  or  any  organic  affec- 
tion of  the  heart.  It  does  not  enter  into  the  scope 
of  this  work  to  discuss  the  validity  of  this  explana- 
tion. The  fact,  however,  that  a  mitral  systolic  mur- 
mur may  exist,  continue  for  weeks  or  months,  and 


CARDIAC    MURMURS.  239 

even  for  years,  and  disappear,  the  murmur  being 
neither  accompanied  nor  followed  by  signs  or  symp- 
toms denoting  organic  disease,  is  an  important  fact 
to  be  borne  in  mind  with  reference  to  diagnosis  and 
prognosis.  The  temporary  occurrence  of  this  mur- 
mur in  chorea  has  been  attributed  to  functional 
incompetency  of  the  valve  due  to  irregular  contrac- 
tion of  the  papillary  muscles. 

Aortic  Direct  Murmur. — This  murmur,  like  the 
mitral  systolic  murmurs,  occurs  with  the  systolic 
sounds  of  the  heart.  Of  the  organic  murmurs  on 
the  left  side  of  the  heart,  the  mitral  systolic  murmurs 
and  the  aortic  direct  murmur  are  synchronous,  the 
others  having  different  relations  with  the  heart- 
sounds.  The  aortic  direct  murmur  differs  from  the 
mitral  systolic  murmurs  in  having  its  maximum  of 
intensity  at  the  base  of  the  heart.  It  is  loudest  in 
the  second  intercostal  space  near  the  sternum.  As 
a  rule,  it  is  louder  in  this  intercostal  space  on  the 
right  than  on  the  left  side;  this  rule,  however,  has 
frequent  exceptions.  It  is  transmitted  better  and 
further  upward  than  downward.  It  is  always  heard 
over  the  carotid  artery ;  and  it  is  sometimes  louder 
over  this  artery  than  at  the  base  of  the  heart.  As  a 
murmur  may  be  produced  within  the  carotid  artery, 
it  is  desirable  to  determine,  when  a  systolic  murmur 
is  h.ard  at  the  base,  whether  the  carotid  murmur  is 
a  transmitted  murmur  or  not.  This  point  is  to  be 
settled  by  comparing  the  murmur  over  tin'  carotid 
with  the  murmur  at  the  base,  as  regards  quality  and 
pitch.  If  tic  quality  and  pitch  of  the  murmur  in 
the  two  situations  lie  the  same,  it  is  lair  to  consider 
the  murmur  in   the  carotid  as   not  produced  within 


240  THE    HEART. 

the  artery,  but  conducted  by  the  blood-current  from 
the  aortic  orifice. 

An  aortic  direct  murmur  is  frequently  inorganic. 
It  is  to  be  considered  as  such  when  it  is  not  asso- 
ciated with  an  aortic  regurgitant  murmur;  when  the 
heart  is  not  enlarged  ;  when  anaemia  is  shown  by  the 
presence  of  murmurs  in  the  large  arteries;  and  when 
there  is  the  venous  hum1  in  the  neck — these  physical 
evidences  of  anaemia  being  associated  generally,  not 
invariably,  with  pallor,  and  with  symptoms  pointing 
to  impoverishment  of  the  blood.  Moreover,  an  in- 
organic murmur  is  very  rarely  rough,  and  it  is  vari- 
able in  its  occurrence,  being  at  one  time  present  and 
at  another  time  absent,  whereas,  an  organic  murmur 
is,  in  general,  constant.  Associated  with  other  evi- 
dence of  anaemia,  an  aortic  direct  murmur  may, 
nevertheless,  be  organic,  but,  under  the  differentiating 
circumstances  just  stated,  the  lesion  represented  by 
the  murmur,  if  the  murmur  be  organic,  must  be  in- 
nocuous, so  that  it  is  not  of  great  practical  impor- 

1  To  obtain  the  venous  hum  (bruit  de  dlable),  cause  the  patient 
to  turn  the  head  as  far  as  practicable  to  the  left,  and  apply  the 
stethoscope  to  the  neck  or  the  right  side,  near  the  clavicle,  behind 
the  sterno-cleido-mastoid  muscle.  Press  the  stethoscope  with 
different  degrees  of  force  before  concluding  that  the  murmur  is 
wanting.  The  venous  hum  is  continuous,  and  closely  resembles 
the  sound  of  the  humming-top.  Gentle  pressure,  with  the  finger 
above  the  stethoscope,  so  as  to  interrupt  the  flow  of  blood  in  the 
veins,  causes  the  murmur  at  once  to  cease.  This  fact  is  proof  of 
its  being  a  venous  murmur.  A  systolic  murmur  heard  with  the 
stethoscope  applied  to  the  neck,  is  an  arterial  murmur,  which  may 
either  be  produced  within  the  artery,  or  transmitted  from  the 
aortic  orifice.  An  arterial  and  a  venous  murmur  in  the  neck  often 
coexist. 


CARDIAC    MURMURS.  241 

tance  to  determine  whether  the  murmur  be  or  be  not 
inorganic. 

Like  the  other  organic  murmurs,  an  aortic  direct 
murmur  varies  in  different  cases  in  intensity,  quality, 
and  pitch.  An  organic  aortic  direct  murmur,  per  se, 
does  not  denote  always  aortic  obstruction.  It  may 
be  due  simply  to  roughness  of  the  membrane  at  or 
above  the  aortic  orifice. 

Aortic  Regurgitant  Murmur — Aortic  Diastolic  Non- 
regurgitant  Murmur,  or  a  Prediastolic  Murmur. — An 
aortic  regurgitant  murmur  occurs  with  the  second 
diastolic  sounds  of  the  heart.  It  is  almost  always 
heard  at  the  base  of  the  heart,  but,  in  some  instances, 
when  not  appreciable  at  the  base,  it  is  heard  a  little 
below  the  base,  namely,  near  the  sternum  on  the 
left  side  on  a  level  with  the  fourth  costal  cartilage. 
In  some  instances,  however,  the  maximum  of  in- 
tensity is  in  a  corresponding  situation  on  the  right 
Bide.  In  the  latter  situations  it  has  generally  its 
maximum  of  intensity.  It  is  transmitted  best  in  a 
downward  direction,  being  often  heard  at  the  apex, 
and  sometimes  considerably  below  this  point.  It  is 
never  inorganic.  It  is  usually  not  intense,  low  in 
pitch,  and  soft;  but  it  may  be  loud,  high,  rough,  or 
musical. 

A  short  murmur  is  sometimes  produced  by  the 
retrograde  movement  of  the  blood-current  within 
the  aorta,  the  aortic  valve  being  intact,  and  regurgi- 
tation not,  therefore,  taking  place.  This  murmur  is 
due  to  roughening  of  the  lining  membrane  of  the 
aorta  by  atheroma  or  calcareous  deposit,  and  it  is 
always  preceded  by  an  aortic  direct  murmur.  It 
occurs  directly  after  the  systole,  and  ends  witb   the 

21 


242  THE    HEART. 

second  sound.  Although  of  such  brief  duration,  it 
is  distinctly  recognizable  and  distinguished  from  the 
preceding  aortic  direct  murmur.  I  have  long  been 
accustomed  to  demonstrate  this  murmur  in  private 
teaching,  and  have  called  it  an  aortic  diastolic  non- 
regurgitant  murmur.  A  better  name  is  a  predias- 
tolic murmur.  It  cannot  be  said  to  have  much 
practical  importance,  inasmuch  as  the  lesion  giving 
rise  to  it  is  represented  by  the  aortic  direct  murmur 
which  precedes  it.  This  murmur  may  be  associated 
with  a  true  regurgitant  murmur.  This  is  the  ex- 
planation of  a  diastolic  murmur  which  is  rough 
before  and  soft  after  the  aortic  second  sound. 

Coexisting  Endocardial  Murmurs. — The  murmurs 
referable  to  the  left  side  of  the  heart,  which  have 
been  considered,  are  often  found  in  combination ; 
two  or  three  may  coexist,  or  all  of  them  may  be 
present.  Moreover,  with  more  or  less  of  these  mur- 
murs may  be  associated  murmurs  referable  to  the 
right  side  of  the  heart.  Having  become  familiar 
with  their  relations  with  the  heart-sounds,  and  other 
points  involved  in  their  differentiation,  it  is  not  diffi- 
cult to  recognize  them  in  combination.  The  mitral 
murmurs  are  not  infrequently  associated.  The 
mitral  direct,  being  presystolic,  ends  with  the  sys- 
tolic sounds,  and  the  mitral  systolic  or  regurgitant 
begins  with  these  sounds;  the  sj-stolic  sounds,  as  it 
were,  divide  these  two  murmurs.  These  murmurs 
almost  invariably  differ  from  each  other  in  pitch  and 
quality.  The  presence  of  both,  in  fact,  assists,  rather 
than  obstructs,  the  recognition  of  each.  The  aortic 
direct  and  the  aortic  regurgitant  murmur,  also,  are 
often  associated.     A  murmur  then  accompanies  the 


CARDIAC    MURMURS.  243 

systolic  and  the  diastolic  sounds  of  the  heart;  the 
two  murmurs  follow  in  the  same  rhythmical  order 
as  the  two  groups  of  heart-sounds.  These  murmurs, 
when  associated,  can  only  be  confounded  with  peri- 
cardial friction-sounds. 

The  combination  of  the  aortic  direct  and  the 
mitral  systolic  murmur  alone  offers  any  difficulty. 
These  two  murmurs  have  the  same  relation  with  the 
heart-sounds;  they  are  both  systolic.  How  is  it  to 
be  determined,  when  a  systolic  murmur  is  heard 
both  at  the  base  and  apex,  whether  a  mitral  mur- 
mur is  transmitted  to  the  base,  or  an  aortic  mur- 
mur is  transmitted  to  the  apex;  in  other  words, 
how  is  it  to  be  decided  whether  two  murmurs  are 
present  or  only  one  murmur?  If  these  two  mur- 
murs coexist,  generally  the  circumstances  which 
distinguish  each  separately  can  be  ascertained. 
Thus,  the  aortic  murmur  is  transmitted  into  the 
carotid  artery,  and  the  presence  of  that  murmur  is 
then  established:  the  mitral  regurgitant  murmur  is 
often  transmitted  laterally  around  the  chest  or  heard 
at  the  lower  angle  of  the  scapula,  and  then  the  pres- 
ence of  that  murmur  is  established.  Bat  there  are 
additional  points,  namely,  the  murmur  at  the  base 
and  that  at  the  apex  generally  differ  sufficiently  in 
pitch  or  quality  to  render  it  evident  that  there  are 
two  murmurs  ;  and  generally  at  a  situation  in  the 
prsecordia  between  the  base  and  apex,  both  murmurs 
niiiv  be  either  lost  or  become  notably  weakened. 
Attention  to  these  points  in  mos1  instances  diveste 
the  problem  of  difficulty. 

Mitral  and  aortic  lesion-  are  often  of  a  character 
to  give  rise  to  only  one  murmur  at  either  of  these 


244  THE    HEART. 

orifices.  A  mitral  direct  murmur  not  infrequently 
is  present  without  the  mitral  regurgitant,  and  the 
reverse  of  this  is  frequent.  So,  either  an  aortic  direct 
or  an  aortic  regurgitant  murmur  may  exist  without 
the  other. 

Tricuspid  Direct  Murmur. — The  lesions  which  are 
requisite  for  this  murmur  very  rarely  occur  at  the 
tricuspid  orifice;  hence,  this  murmur  is  exceedingly 
rare.  It  is  to  be  distinguished  from  the  mitral  direct 
murmur  by  its  localization  being,  not  at  the  apex, 
but  at  the  right  border  of  the  heart.  The  mitral 
direct  and  the  tricuspid  direct  murmur  may  coexist; 
an  instance  of  this  kind  has  fallen  under  my  observa- 
tion. In  that  instance  a  presystolic  murmur,  with 
the  characteristic  blubbering  quality,  was  heard  both 
at  the  apex  and  at  the  right  side  of  the  heart. 

Tricuspid  Regurgitant  Murmur. —  This  murmur  is 
not  of  infrequent  occurrence.  Tricuspid  regurgita- 
tion occurs  often  when  the  right  ventricle  is  con- 
siderably dilated,  without  the  existence  of  lesions  of 
the  valve.  A  tricuspid  regurgitation  current,  how- 
ever, does  not  invariably  give  rise  to  an  appreciable 
murmur.  This  fact  is  shown  by  the  occurrence  of  a 
venous  pulse  in  the  neck,  due  to  tricuspid  regurgita- 
tion, when  no  murmur  can  be  heard. 

The  tricuspid  regurgitant  murmur,  of  course, 
occurs  with  the  first  or  systolic  sound,  being  systolic 
like  the  mitral  regurgitant  murmur,  and  the  latter 
generally  coexists.  It  is  distinguished  from  the 
mitral  regurgitant  by  its  localization  at  the  right 
inferior  margin  of  the  heart,  and  its  transmission  to 
the  right  rather  than  to  the  left.  The  coexistence 
of  the  mitral  and  the  tricuspid  regurgitant  murmur 


CARDIAC    MURMURS.  245 

is  determined  by  the  differences  in  pitch  and  quality 
between  a  systolic  murmur  at  the  apex  and  at  the 
right  margin  of  the  heart.  A  venous  pulse,  syn- 
chronous with  the  first  sound  of  the  heart,  points  to 
tricuspid  regurgitation,  and,  although  sometimes 
present  without  a  tricuspid  regurgitant  murmur, 
when  present  it  is  corroborative  evidence  of  the 
latter.1 

Pulmonic  Direct  Murmur. — A  pulmonic  direct 
murmur,  if  organic,  is  generally  connected  with  con- 
genital lesions.  The  pulmonic  direct  and  the  aortic 
direct  current  of  blood  taking  place  at  the  same 
instant,  the  murmurs  representing  both  are,  of 
course,  systolic.  How  is  the  pulmonic  to  be  dis- 
tinguished from  the  aortic  direct  murmur?  The 
pulmonic  murmur  is  heard  in  the  left  second  inter- 


1  Pulsation  of  the  cervical  veins  is  a  not  infrequent  sign  in  cases 
of  enlargement  of  the  right  side  of  the  heart.  The  pulsation  in 
the  veins  is  visible,  but  very  rarely  appreciable  by  the  touch.  It 
is  to  be  distinguished  from  pulsation  of  the  arteries  of  the  neck. 
This  is  easily  done  by  finding  that  pressure  just  above  the  clavicle 
sufficient  to  interrupt  the  flow  of  blood  in  the  veins,  but  not  in  the 
arteries,  abolishes  the  pulsation.  The  venous  pulse  is  generally 
due  to  a  tricuspid  regurgitant  current,  and  is  therefore  caused  by 
the  contraction  of  the  right  ventricle.  It  may,  however,  be  caused 
by  the  contraction  of  the  right  auricle.  If  caused  by  the  contrac- 
tion of  right  ventricle  giving  rise  to  tricuspid  regurgitation,  the 
venous  pulse  is  synchronous  with  the  carotid  pulse,  the  systolic 
sounds  of  the  heart,  and  the  apex-beat.  If  caused  by  the  con 
tion  "f  the  right  auricle,  the  venous  pulse  precedes  the  carotid  pulse  ; 
it  is  presystolic.  A  venous  pulse  thus  may  be  either  ventricular  or 
auricular,  and  the  differentiation  is  easily  made.  There  may  be 
both  a  ventricular  and  an  auricular  venous  pulse,  t! ne  syn- 
chronous with,  and  the  other  preceding,  tin-  carotid  pulse.  Pulsa- 
tion is  sometimes  observed  in  other  veins  than  those  of  the  neck — 
the  brachial,  femoral,  and  even  veins  -till  more  remote  from  the 

heart. 

21* 


246  THE    HEART. 

costal  space  close  to  the  sternum  ;  but  this  is  not 
very  distinctive,  inasmuch  as,  not  infrequently,  the 
aortic  murmur  is  loudest  in  that  situation.  The 
essential  point  of  distinction  is  this :  the  pulmonic 
direct  murmur  is  not  transmitted  into  the  carotid 
artery,  whereas,  the  aortic  direct  murmur  is  always 
thus  transmitted.  If  an  aortic  direct  and  a  pulmonic 
direct  murmur  coexist,  hoth  being  organic,  the  com- 
bination is  to  be  ascertained  by  finding  that  the 
murmur  in  the  second  intercostal  space  on  the  right 
side  differs  from  that  on  the  left  side  in  pitch  or 
quality  sufficiently  to  show  the  presence  of  these 
murmurs,  the  one  on  the  right  side  being  transmitted 
to  the  carotid  artery. 

An  inorganic  or  functional  pulmonic  direct  mur- 
mur is  of  frequent  occurrence  in  cases  of  ansemia. 
It  is  frequently  associated  with  an  inorganic  aortic 
direct  murmur,  the  presence  of  the  two  murmurs 
being  evidenced  by  a  difference  in  pitch.  The  theory 
of  Waunym,  that  the  systolic  functional  murmur 
heard  in  the  left  second  intercostal  space  near  the 
sternum,  and  generally  referred  to  the  pulmonic 
orifice,  is  not  a  pulmonic,  but  a  mitral  regurgitant 
murmur  conducted  by  the  dilated  appendix  of  the 
left  auricle,  has  been  elaborately  advocated  by  Dr. 
Balfour,  of  Edinburgh.  This  theory  is  so  strained 
and  fanciful,  that  it  hardly  deserves  the  discussions 
which  it  has  received  from  others.  It  is  certain  that 
a  mitral  regurgitant  murmur  due  to  mitral  lesions 
has  its  maximum  of  intensity  at  or  near  the  apex  of 
the  heart.  Why  should  a  murmur  hypothetically 
referred  to  functional  incompetency  of  the  mitral 


CARDIAC    MURMURS.  247 

valve  be  heard  above  the  base  of  the  heart  and  not 
at  the  apex? 

Pulmonic  Regurgitant  Murmur. —  This  murmur  is 
exceedingly  rare  in  consequence  of  the  infrequency 
of  pulmonic  regurgitant  lesions.  It  occurs,  of  course, 
like  the  aortic  regurgitant,  with  the  second  or  dias- 
tolic sound.  Its  presence  can  only  be  determined 
when  other  signs  go  to  show  the  existence  of  pul- 
monic and  the  absence  of  aortic  lesions.  This  mur- 
mur, as  well  as  the  aortic  regurgitant,  can  never  be 
inorganic,  its  presence  being  proof  of  a  regurgitant 
current  of  blood  from  incompetency  of  the  pulmonic 
valve.1 

Facts  of  practical  importance  in  relation  to  the 
endocardial  murmurs,  are  embraced  in  the  following 
statements  : 

The  question  as  to  a  murmur  being  organic  or 
inorganic,  relates  chiefly,  if  not  entirely,  to  the  aortic 
direct  and  the  pulmonic  direct  murmur,  other  mur- 
murs being  almost  invariably  organic. 

Associated  signs  and  symptoms  generally  warrant 
a  definite  conclusion  whether  an  aortic  direct  or  a 
pulmonic  direct  murmur  be,  or  be  not,  organic,  and 
under  the  circumstances  which  render  it  difficult  to 
decide  this  question  positively,  a  positive  decision  is 
not  of  much  immediate  practical  consequence. 

Valvular  lesions,  whether  obstructive,  regurgitant, 
or  innocuous,  are  so  uniformly  represented  by  mur- 
mur, that,  as  a  rule,  absence  of  lesions  may  be  predi- 
cated on  the  absence  of  murmur. 

1  I  have  met  with  an  instance  in  which  it  existed,  and  was 
attributed  t"  pressure  from  without. 


218  THE    HEAKT. 

With  a  practical  knowledge  .of  the  different  organic 
murmurs,  the  situation  of  lesions  at  either  of  the 
orifices  of  the  heart,  or  their  existence  at  two  or 
more  of  these  orifices,  may  be  demonstratively  de- 
termined. 

By  means  of  the  murmurs,  with  other  signs,  it 
may  be    determined   demonstratively  whether  the 
lesions  involve  obstruction  or  regurgitation,  or  both, 
or,  on  the  other  hand,  that  they  are,  as  regards  im 
mediate  pathological  effects,  innocuous. 

The  murmurs  do  not  afford  definite  information 
as  to  the  amount  of  obstruction  or  regurgitation,  in 
other  words,  as  to  the  pathological  importance  or 
gravity  of  lesions  when  they  are  not  innocuous.  No 
positive  conclusions  on  this  point  of  view  are  to  be 
drawn  from  the  intensity  of  murmurs,  their  pitch,  or 
their  quality.  As  a  rule,  murmurs  which  are  weak, 
more  than  those  which  are  loud,  represent  grave 
lesions. 

Pericardial  or  Friction  Murmur. — A  pericardial  or 
friction  murmur  is  produced  by  the  rubbing  together 
of  the  surfaces  of  the  pericardium  in  the  systolic  and 
diastolic  movements  of  the  heart.  In  the  vast  ma- 
jority of  the  cases  in  which  this  murmur  occurs,  it 
denotes  either  the  presence  of  recent  lymph  which 
renders  the  surfaces  more  or  less  adhesive,  or  rough- 
ening from  lymph  which  has  become  dense  and 
adherent;  its  diagnostic  significance,  therefore,  re- 
lates almost  exclusively  to  pericarditis.  In  this 
•relation  it  is  of  great  practical  importance. 

This  exocardial  murmur  is  to  be  discriminated 
from  the  endocardial  murmurs.  The  points  involved 
in  the  discrimination  are  as  follows :  The  murmur 


CARDIAC    MURMURS.  249 

is  double,  that  is,  a  murmur  accompanies  both  the 
ventricular  systole  and  diastole.  It  can,  therefore, 
only  be  confounded  with  an  aortic  direct  and  an 
aortic  regurgitant  murmur  in  combination.  The 
quality  of  the  murmur  is  suggestive  of  rubbing  or 
friction.  It  is  sometimes  a  feeble,  grazing  sound  : 
in  other  instances  it  is  loud  and  rough.  When 
rough,  the  quality  is  expressed  by  such  terms  as 
rasping,  grating,  creaking,  etc.  Although  accom- 
panying both  the  systolic  and  diastolic  sounds  of  the 
heart,  it  has  not  that  uniform,  fixed  relation  to  these 
sounds  which  characterizes  the  aortic  direct  and  the 
aortic  regurgitant  murmur;  it  is  not  in  definite 
accord  with  the  heart-sounds.  Moreover,  in  inten- 
sity it  varies  with  the  successive  movements  of  the 
heart,  being  louder  with  some  revolutions  than  with 
others,  in  this  regard  differing  notably  from  the 
endocardial  murmurs.  It  is  not  heard  without  the 
prsecordia,  as  a  rule,  and  is  often  limited  to  a  part  of 
the  precordial  region,  whereas,  certain  of  the  endo- 
cardial murmurs,  namely,  the  mitral  regurgitant  and 
the  aortic  direct,  are  often  heard  at  a  considerable 
distance  from  the  heart.  Firm  pressure  with  the 
stethoscope  and  often  a  forced  expiration  intensity 
the  murmur.  Its  source  seems  very  near  the  surface 
of  the  chest.  In  this  respect  it  differs  notably  from 
endocardial  murmurs,  the  latter  appearing  to  come 
from  a  certain  distance  within  the  chest.  This  point 
of  distinction  is  very  appreciable,  especially  if,  as 
often  happens,  a  friction  murmur  be  associated  with 
an  endocardial  murmur. 


CHAPTER  VIII. 

THE    PHYSICAL    DIAGNOSIS    OF    DISEASES    OF    THE 
HEAET  AND  OF  THORACIC  ANEURISM. 

Enlargement  of  the  heart  by  hypertrophy  and  dilatation — Valvular 
lesions,  mitral,  aortic,  tricuspid,  and  pulmonic — Fatty  degeneration 
and  softening  of  the  heart — Endocarditis — Pericarditis — Functional 
disorders — Thoracic  aneurism. 

The  morbid  physical  conditions  incident  to  the 
different  diseases  of  the  heart,  and  the  signs  repre- 
senting these  conditions,  have  been  considered  in  the 
preceding  chapter.  The  diseases  are  not  to  be  con- 
sidered with  reference  to  the  assemblage  of  signs  on 
which  the  physical  diagnosis  of  each  is  to  be  based. 
Most  of  the  diseases  of  the  heart  may  be  diagnosti- 
cated by  means  of  physical  signs.  A  few  cardiac 
lesions  do  not  admit  of  a  physical  diagnosis,  and  they 
do  not,  therefore,  claim  consideration  in  this  work. 
The  following  are  the  affections  which  will  form 
separate  headings  in  this  chapter:  Enlargement  of 
the  Heart  by  Hypertrophy  and  by  Dilatation,  Val- 
vular Lesions,  Fatty  Degeneration  and  Softening  of 
the  Heart,  Endocarditis,  Pericarditis,  and  Functional 
Disorders.  Having  considered  these  affections,  the 
physical  diagnosis  of  thoracic  aneurism  will  be  the 
concluding  topic. 

Enlargement  of  the  Heart  by  Hypertrophy  and  by 
Dilatation. — Physical  exploration  to  determine  the 
size  of  the  heart  has  three  objects,  namely,  to  deter- 


ENLARGEMENT    OF    THE    HEART.  i2ol 

mine,  first,  that  the  size  of  the  heart  is  normal,  or 
second,  that  the  heart  is  enlarged,  and,  third,  the 
degree  of  enlargement.  These  ohjects  are  attainable 
by  means  of  percussion  and  auscultation. 

The  heart  is  of  normal  size  when  the  apex-beat  is 
in  its  normal  situation,  that  is,  in  the  fifth  intercostal 
space,  a  little  within  a  vertical  line  passing  through 
the  nipple  (the  linea  mammillaris);  when  the  super- 
ficial cardiac  space  is  not  enlarged,  as  shown  by 
percussion  and  by  auscultation  of  the  voice  (wife  page 
20G),  and  when  percussion  shows  the  lateral  borders 
of  the  heart  to  be  situated  normally,  namely,  on  the 
left  side  a  little  within  the  line  of  the  nipple,  and  on 
the  right  side  of  a  finger's  breadth  to  the  right  of  the 
right  margin  of  the  sternum.  These  points  of  evi- 
dence warrant  a  positive  conclusion  that  the  heart  is 
not  enlarged. 

The  fact  of  an  enlargement  and  its  degree  are  de- 
terminable by  an  abnormal  situation  of  the  apex, 
together  with  an  increase  of  the  superficial  cardiac 
space  and  extension  of  the  lateral  boundaries  of  the 
deep  cardiac  space,  especially  on  the  left  side. 

In  cases  of  slight  or  very  moderate  enlargement, 
the  apex  is  situated  a  little  without  the  linea  mam- 
millaris, but  not  below  the  fifth  intercostal  space.  A 
somewhat  greater  enlargement  lowers  the  apex  to 
the  sixth  intercostal  space,  and  removes  it  further 
without  the  line  of  the  nipple.  In  greater  degrees 
of  enlargement  the  apex  is  lowered  to  the  seventh, 
eighth,  or  ninth  intercostal  space,  and  generally 
further  removed  to  the  left.  The  lowering  of  the 
apex  and  the  removal  to  the  left,  are  not  uniformly 
proportionate  to  each  other.     As  a  rale,  if  the  righl 


252  DISEASES    OF    THE    HEART. 

siilo  of  the  heart  be  more  enlarged  than  the  left,  the 
apex  is  removed  without  the  linea  mammillaris  fur- 
ther than  when  the  enlargement  of  the  left  side  of 
the  heart  predominates,  and  when  the  latter  is  the 
ease,  the  apex  is  lowered  out  of  proportion  to  its  re- 
moval without  that  line.  The  relatively  abnormal 
situation  downward  and  to  the  left,  thus,  is  evidence 
of  the  enlargement  predominating  in  either  the  right 
or  the  left  side  of  the  heart.1  Generally  the  situation 
of  the  apex  is  apparent  to  the  touch  and  frequently 
to  the  eye.  In  some  instances,  however,  the  impulse 
can  neither  be  seen  nor  felt.  How  is  its  situation  to 
be  then  ascertained  ?  Auscultation  furnishes  a  ready 
and  reliable  mode  of  determining  this  point.  The 
situation  in  which  the  first  sound  of  the  heart  has  its 
maximum  of  intensit}7,  as  ascertained  by  means  of 
the  stethoscope,  corresponds  to  the  situation  of  the 
apex.  This  is  hardly  less  definite  than  the  presence 
of  an  appreciable  impulse. 

In  determining  the  fact  of  enlargement  and  its 
degree  by  the  abnormal  situation  of  the  apex,  causes 
of  the  latter  which  are  extrinsic  to  the  heart  are  to 
be  eliminated.  The  apex  is  removed  to  the  left  of 
its  normal  situation  by  enlargement  of  the  left  lobe 

1  In  some  diagrammatic  illustrations — e.  g.,  Weil  and  Van  Dusch 
— the  relatively  greater  removal  of  the  apex,  either  to  the  left  or 
downward,  indicating  that  the  enlargement  predominates  either  in 
the  right  or  the  left  ventricle,  is  represented  as  precisely  the  reverse 
of  the  statements  here  made.  In  these  illustrations  the  extension 
of  the  area  occupied  by  the  heart  is  in  a  direction  to  the  right  if 
the  right  ventricle  be  predominantly  enlarged,  and  to  the  left  if 
the  enlargement  predominates  in  the  left  ventricle.  The  illustra- 
tions are  based  on  theoretical  conclusions.  Clinical  observation 
slmws  them  to  he  erroneous. 


ENLARGEMENT    OF    THE    HEART.  253 

of  the  liver,  abdominal  tumors,  hydroperitoneuni, 
the  pregnant  uterus,  and  gastric  tympanites.  These 
extrinsic  conditions  are  to  be  excluded  or  due  allow- 
ance made  for  them.  In  some  cases  in  which  one 
or  more  of  these  extrinsic  causes  of  displacement 
may  exist,  the  apex  is  carried  into  the  axillary  regicm. 
It  is  to  be  borne  in  mind  that  these  causes  of  dis- 
placement may  exist  when  there  is  more  or  less 
enlargement  of  the  heart.  All  these  causes,  while 
they  displace  the  apex  to  the  left,  do  not  lower,  but 
tend  to  raise  it  above,  its  normal  situation.  On  the 
other  hand,  an  aneurismal  or  other  tumor,  situated 
above  the  heart,  may  press  downward  the  organ, 
and  in  this  way  the  apex  is  more  or  less  lowered.1 

The  superficial  cardiac  space  is  increased  in  pro- 
portion as  the  heart  is  enlarged.  The  extent  of  this 
increase  is  easily  determined  by  percussion  and  aus- 
cultation. Within  this  space  there  is  notable  dulness 
oh  percussion.  The  degree  of  dulness  is  greater 
than  within  the  superficial  cardiac  space  in  health, 
and  this  degree  of  dulness  is  proportionate  to  the 
greater  area  in  which  the  heart  is  uncovered  of  lung. 
It  is  easy  to  delineate  by  percussion  on  the  chest  the 
boundary  of  the  anterior  border  of  the  upper  lobe  of 
the  left  lung,  in  other  words,  of  the  oblique  line 
which  is  the  hypothenuse  of  the  right-angled  triangle 
representing  the  superficial  cardiac  space  in  health 
and  in  disease.  The  area  of  the  superficial  cardiac 
space  is  also  not  less  readily  and  precisely  ascertained 
by  auscultation  of  the  voice;  the  limits  of  the  lung 
within  the  prsecordia  are  denoted  by  an  abrupt  ces- 

1   Professor  Jane  way  states  thai  be  has  known  Iheapex  lowered 
hs  an  unusually  long  first  portion  of  the  aortic  arch. 


254  DISEASES    OF    THE    HEART. 

sation  or  notable  diminution  of  the  vocal  resonance. 
In  women  with  large  mammae  auscultation  is  more 
available  for  this  object  than  percussion.  The  ex- 
tent to  which  the  superficial  cardiac  space  is  enlarged 
is  a  good  criterion  of  the  degree  of  the  enlargement 
of  the  heart. 

In  proportion  as  the  heart  is  enlarged,  the  situa- 
tion of  the  left  border  is  without  the  linea  mammil- 
laris.  Its  situation  is  determined  by  percussion. 
Dulness,  although  not  great,  is  sufficiently  distinct 
within  the  deep  cardiac  space,  and  the  line  which 
denotes  the  left  border  of  the  heart  is  easily  delineated 
on  the  chest.  This  statement  holds  true  with  respect 
to  the  right  border  of  the  heart;  but  this  border, 
even  when  the  enlargement  of  the  heart  is  great,  is 
removed  comparatively  little  to  the  right  of  its  nor- 
mal situation.  By  means  of  percussion  the  bound- 
aries of  the  prsecordia  as  enlarged  by  the  increased 
size  of  the  heart  may  be  determined  and  measured. 
In  making  this  statement,  it  is  assumed  that  the 
lungs  are  not  diseased,  and  that  the  chest  is  not  de- 
formed. Shrinkage  of  the  upper  lobe  of  the  left 
lung  may  enlarge  the  superficial  cardiac  space,  and 
cause  displacement  of  the  heart.  The  latter  is  an 
effect  of  the  presence  of  pleuritic  effusion,  and  it 
may  follow  its  removal.  In  cases  of  deformity  from 
spinal  curvature,  to  determine  the  fact  of  enlarge- 
ment of  the  heart,  or  its  degree,  is  not  always  an 
easy  problem. 

There  is  a  liability  to  error  in  localizing  the  apex 
in  some  cases  of  enlargement.  Owing  to  the  blunted 
form  of  the  apex,  especially  when  the  enlargement 
is  chiefly  of  the  right  side  of  the  heart,  the  apex-beat 


ENLARGEMENT    OF    THE    HEART.  255 

may  be  feeble.  It  is  liable  to  be  overlooked,  and  a 
stronger  impulse  in  the  intercostal  space  above  the 
apex  mistaken  for  the  apex-beat.  Of  course,  the 
lowest  impulse  is  the  apex-beat.  Careful  palpation, 
and  finding  by  auscultation  the  spot  where  the  first 
sound  has  its  maximum  of  intensity,  will  prevent 
this  error. 

Enlargement  of  the  heart,  and  the  degree  of  en- 
largement having  been  ascertained,  it  is  to  be 
determined  whether  hypertrophy  or  dilatation  pre- 
dominate. If  the  enlargement  be  slight  or  moderate, 
it  may  be  a  question  whether  hypertrophy  or  dilata- 
tion exist  alone.  As  a  rule,  if  either  of  these  two 
forms  of  enlargement  exist  without  the  other,  it  is 
hypertrophy,  for,  with  rare  exceptions,  hypertrophy 
precedes  dilatation.  If  the  enlargement  be  very 
great,  as  a  rule,  dilatation  predominates,  for  the 
capability  of  hypertrophic  increase  of  size  has  its 
limit,  and  an  increase  of  size  beyond  this  limit  must 
be  due  to  dilatation. 

The  signs,  denoting  on  the  one  hand  hypertrophy, 
and  on  the  other  hand  dilatation,  relate  to  the 
impulses  of  the  heart  and  to  the  heart-sounds. 
With  a  moderate  enlargement,  hypertrophy  is  to 
be  inferred  from  an  abnormal  force  of  the  apex-beat, 
and  an  intensification  of  the  systolic  sounds,  espe- 
cially the  sound  of  impulsion  over  the  apex.  With 
a  considerable  or  great  enlargement,  if  hypertrophy 
predominate,  the  apex-beat  may  be  abnormally 
strong  and  prolonged,  but,  as  already  stated,  owing 
to  its  blunted  form,  the  beat  is  sometimes  weak  and 
Bcarcely  appreciable;   the   increased   power  of  the 


256  DISEASES    OF    THE    HEART. 

ventricular  contractions,  representing  the  hyper- 
trophy, is  then  to  be  determined  by  impulses  in  the 
intercostal  spaces  above  the  apex.  These  impulses 
are  sometimes  present  in  each  intercostal  space  be- 
tween the  apex  and  the  base,  and  they  are  abnor- 
mally strong  in  proportion  as  hypertrophy  predomi- 
nates. Still  more  marked  evidence  of  hypertrophy 
is  sometimes  obtained  when  the  hand  is  placed  over 
the  prsecordia;  a  powerful  heaving  movement  is  felt. 
The  increased  power  of  the  ventricular  contractions 
may,  in  some  cases,  be  in  this  way  appreciated  some- 
what as  if  the  heart  were  held  in  the  hand.  In  cases 
of  considerable  or  great  hypertrophic  enlargement, 
the  intensity  of  the  sound  of  impulsion  over  the  apex 
s  notably  increased ;  it  is  prolonged,  and  its  booni- 
ng  quality  is  more  marked  than  in  health.  Not 
nfrequently  it  is  accompanied  by  a  metallic  ringing 
sound,  or  tinnitus. 

Moderate  enlargement  by  dilatation  is  character- 
ized by  abnormal  weakness  of  the  apex-beat  and  of 
the  systolic  sounds  over  the  apex.  Cases,  however, 
of  simple  dilatation  are  rare.  If  the  enlargement  be 
considerable  or  great,  and  dilatation  predominate, 
all  the  impulses  are  weak,  as  compared  with  the 
cases  in  which  hypertrophy  predominates,  and  the 
sound  of  impulsion  over  the  apex  is  diminished  or 
nil,  the  feeble,  short,  mitral  valvular  sound  either 
supplanting  or  predominating  over  the  sound  of  im- 
pulsion. These  points  of  distinction  are  marked  in 
proportion  as  dilatation  predominates. 

In  the  great  majority  of  the  cases  of  enlargement 
of  the  heart,  valvular  lesions  coexist.  These  co- 
existing valvular  lesions  are  represented  by  endo- 


VALVULAR    LESIONS.  257 

cardial  murmurs,  and  they  may  generally  be  excluded 
by  the  absence  of  the  latter.  In  most  of  the  cases 
in  which  enlargement  exists  without  valvular  lesions, 
it  is  associated  with  either  pulmonary  emphysema 
or  chronic  Bright's  disease. 

Valvular  Lesions. 

The  physical  diagnosis  of  valvular  lesions  embraces 
their  localization  at  the  different  orifices  within  the 
heart,  and  the  determination  of  their  character  as 
giving  rise  to  obstruction  and  regurgitation,  or  of 
their  innocuousness  in  these  respects.  These  objects 
of  diagnosis  involve  the  endocardial  murmurs  and 
the  abnormal  modifications  of  the  heart-sounds  which 
were  considered  in  the  preceding  chapter.  Lesions 
at  the  different  orifices,  namely,  the  mitral,  aortic, 
tricuspid,  and  pulmonic,  will  be  considered  sepa- 
rately. 

Mitral  Lesions. — The  lesions  at  the  mitral  orifice 
are  represented  by  the  mitral  murmurs — the  mitral 
direct  murmur,  the  mitral  regurgitant,  the  mitral 
systolic  non-regurgitant  or  intra-ventricular,  and  the 
mitral  diastolic  murmur.  Mitral  obstructive  lesions 
exist  whenever  the  mitral  direct  murmur  is  present, 
with  an  exception  already  stated  and  explained  {vide 
p.  233),  namely,  this  murmur  is  present  in  some 
cases  in  which  the  mitral  valve  is  intact,  aortic 
lesions,  giving  rise  to  free  regurgitation,  existing  in 
these  cases.  These  exceptional  instances  are  rare, 
and  1  am  not  aware  that  any  have  been  reported 
except  by  myself. 
Mitral  regurgitant  Lesions  exist  whenever  a  mitral 
22* 


258  DISEASES    OF    THE    HEART. 

murmur  which  is  truly  regurgitant  is  present.  A 
systolic  murmur  having  its  maximum  of  intensity  at 
or  near  the  apex,  transmitted  laterally  for  a  certain 
distance  beyond  the  apex  on  the  left  side  of  the  chest, 
and  heard  on  the  back  near  the  lower  angle  of  the 
scapula,  generally,  if  not  invariably,  denotes  a  re- 
gurgitant current ;  but  a  systolic  murmur  limited  to 
a  small  area  around  the  apex,  or  to  the  superficial 
cardiac  space,  is  not  proof  of  regurgitation.  A  truly 
regurgitant  murmur,  however,  may  be  too  feeble  to 
be  transmitted  beyond  the  apex ;  the  proof  of  regur- 
gitation must  then  be  based  on  other  evidence  asso- 
ciated  with  the  murmur,  namely,  on  enlargement  of 
the  heart  and  abnormal  modifications  of  the  heart- 
sounds. 

Mitral  obstruction  may  exist  without  incompetency 
of  the  mitral  valve,  as  shown  by  the  presence  not 
very  infrequently  of  a  mitral  direct,  without  a  mitral 
regurgitant,  murmur.  The  converse  of  this  is  of 
more  frequent  occurrence,  that  is,  regurgitation  may 
exist  without  obstruction.  The  absence,  however, 
of  a  mitral  direct  murmur  is  not  positive  proof 
against  mitral  lesions,  for,  as  has  been  seen,  the  pro- 
duction of  a  characteristic  mitral  direct  murmur  re- 
quires the  obstruction  to  be  caused  by  an  adherence 
of  the  mitral  curtains  at  their  sides,  the  curtains 
being  sufficiently  flexible  to  vibrate  with  the  passage 
of  the  mitral  direct  current  of  blood.  If  these  con- 
ditions for  the  production  of  the  murmur  do  not 
exist,  there  may  be  no  murmur  produced  by  the 
mitral  direct  current;  or,  if  a  murmur  be  present,  it 
is  devoid  of  the  usual  characteristic  quality.  Mitral 
obstruction  and  regurgitation  not  infrequently  co- 


VALVULAR    LESIONS.  259 

exist,  as  shown  by  the  presence  of  both  the  mitral 
direct  and  the  mitral  regurgitant  murmur.  A  mitral 
murmur,  produced  by  a  mitral  direct  current,  but 
diastolic  in  point  of  time,  is  sometimes,  as  has  been 
seen  (vide  page  236),  observed  in  connection  with 
mitral  lesions.  The  significance  of  this  murmur, 
except  that  it  denotes  mitral  lesions,  is  not  yet 
ascertained. 

The  mitral  murmurs  do  not,  per  se,  denote  the 
amount  of  obstruction  or  regurgitation,  or  of  both 
combined.  Information  with  reference  to  these 
points  may  be  derived,  in  the  first  place,  from  a 
comparison  of  the  aortic  with  the  pulmonic  second 
sound.  The  amount  of  obstruction  or  regurgitation, 
or  both,  is  great  in  proportion  as  the  aortic  sound  is 
weakened.  Per  contra,  there  can  be  but  little  ob- 
struction or  regurgitation  if  the  aortic  and  the  pul- 
monic second  sound  preserve  completely  or  nearly 
their  normal  relation  to  each  other  in  respect  of 
intensity.  Information  may,  in  the  second  place,  be 
obtained  by  directing  attention  to  the  mitral  valvular 
sound  (vide  page  225).  In  proportion  as  the  function 
of  the  mitral  valve  is  compromised  by  lesions,  the 
mitral  valvular  sound  at  the  apex  will  be  weakened. 
In  some  cases  this  sound  is  lost,  the  sound  of  impul- 
sion remaining. 

Enlargement  of  the  right  side  of  the  heart,  which 
results  from  mitral  obstructive  and  regurgitant 
lesions,  is  a  criterion  of  the  amount  of  obstruction 
and  regurgitation  taken  in  connection  with  the 
length  of  time  in  which  they  have  existed.  Hyper- 
trophic enlargement  of  the  right  ventricle  intensities 
the  pulmonic  second  sound,  and  allowance  must    be 


260  DISEASES    OF    THE    HEART. 

made  for  this  modification  in  determining,  by  a 
comparison  of  the  pulmonic  and  the  aortic  sound, 
the  degree  in  which  the  latter  is  weakened.  Atten- 
tion is  to  be  given  to  the  tricuspid  valvular  sound 
(vide  page  224).  The  intensity  of  this  sound  is,  in 
some  measure,  a  criterion  of  the  power  of  the  right 
ventricular  systole. 

Aortic  Lesions. — Lesions  are  localized  at  the  aortic 
orifice  by  the  aortic  murmurs,  namely,  the  aortic 
direct  and  the  aortic  regurgitant  murmur.  Aortic 
obstructive  lesions  give  rise  to  an  aortic  direct  mur- 
mur; but  it  must  be  considered,  in  the  first  place, 
that  an  aortic  direct  murmur  may  be  inorganic,  and, 
in  the  second  place,  that,  if  the  murmur  be  organic, 
it  may  be  produced  by  lesions  which  occasion  no  ob- 
struction, and  are  consequently  innocuous.  The 
existence  of  obstructive  lesions  must  be  determined 
by  evidence  added  to  the  presence  of  the  murmur. 
This  evidence  is  either  diminished  intensity  or  sup- 
pression of  the  aortic  second  sound,  and  enlarge- 
ment of  the  left  ventricle.  If  the  lesions  which 
occasion  obstruction  are  of  a  character  to  diminish 
or  arrest  the  movements  of  the  aortic  valve,  the 
aortic  second  sound  will  be  either  weakened  or  lost. 
If  valvular  lesions  be  limited  to  the  aortic  orifice, 
the  degree  of  enlargement  of  the  left  ventricle  is  a 
criterion  of  their  pathological  importance. 

Regurgitant  lesions  at  the  aortic  orifice  give  rise 
to  an  aortic  regurgitant  murmur.  This  murmur,  of 
course,  is  always  proof  of  regurgitation  ;  but  the 
murmur  gives  no  definite  information  concerning 
the  amount  of  incompetency  of  the  aortic  valve.  A 
loud  murmur  may  be  produced  by  a  regurgitant 


TRICUSPID    LESIONS.  261 

stream  so  small  as  to  bo,  for  the  time,  insignificant  ; 
and,  on  the  other  hand,  a  large  regurgitant  current 
may  give  rise  to  a  feeble  murmur.  The  extent  to 
which  the  valve  is  damaged  by  the  lesions,  is  to  be 
determined,  first,  by  either  weakness  or  suppression 
of  the  aortic  sound,  and,  second,  by  the  degree  of 
enlargement  of  the  left  ventricle. 

Aortic  obstructive  and  regurgitant  lesions  are 
often  associated.  An  aortic  direct  and  an  aortic 
regurgitant  murmur  are  then  both  present,  with  a 
weakened  aortic  sound  or  its  suppression,  and  en- 
largement of  the  left  ventricle  according  to  the 
amount  of  the  obstruction  and  regurgitation,  to- 
gether with  the  length  of  time  during  which  the 
latter  have  existed.  These  effects,  and  not  the 
intensity,  nor  the  pitch,  nor  the  quality  of  the 
murmurs,  are  indicative  of  their  pathological  im- 
portance. 

Mitral  and  aortic  lesions  often  coexist,  giving  rise 
to  two,  three,  or  four  of  the  obstructive  and  regur- 
gitant murmurs  in  the  left  side  of  the  heart.  In 
addition  to  the  murmurs  in  these  cases,  the  effects  of 
the  combined  lesions  are  shown  in  the  modification 
of  the  heart-sounds,  and  enlargement  of  both  sides 
of  the  heart. 

Trvcuspd  Lesions. — Tricuspid  obstructive  lesions 
are  exceedingly  rare.  A  few  instances  of  the  kind 
of  obstruction  which  is  represented  by  a  tricuspid 
direct  or  presystolic  murmur,  have  been  reported. 
One  instance  has  fallen  under  my  observation.  In 
this  case,  as  in  the  other  instances  which  have  been 
reported,  the  tricuspid  were  associated  with  mitral 
lesions:    hence,  in  localizing  an  obstructive  lesion  at 


262  DISEASES    OF    THE    HEART. 

the  tricuspid  orifice,  the  presence  of  the  presystolic 
murmur  on  each  side  of  the  heart,  that  is,  the  coex- 
istence of  mitral  and  tricuspid  direct  murmur  is  to 
be  determined.  This  point  has  already  been  con- 
sidered (vide  page  244). 

Tricuspid  regurgitation  is  not  uncommon.  Gen- 
erally the  insufficiency  is  caused  by  dilatation  of  the 
right  ventricle  occurring  as  an  effect  of  mitral  regur- 
gitant or  obstructive  lesions.  Tricuspid  regurgita- 
tion is  not  always  represented  by  murmur;  and 
when  a  tricuspid  regurgitant  murmur  is  present,  it 
is  to  be  discriminated  from  a  coexisting  mitral  re- 
gurgitant murmur.  This  point  has  been  considered 
(vide  page  244).  A  sign  of  free  tricuspid  regurgita- 
tion with  hypertrophy  of  the  right  ventricle,  is  pul- 
sation of  the  liver,  which  may  be  seen  and  felt. 
This  pulsation  is  sometimes  notably  strong.  If  the 
liver  be  enlarged,  the  pulsation  may  be  communi- 
cated to  the  greater  part  of  the  abdomen,  and  its 
force  may  be  suggestive  of  aneurism  of  the  ab- 
dominal aorta.  Pulsation  of  the  liver  may  be  ob- 
served when  there  is  no  jugular  pulse  nor  notable 
turgescence  of  the  cervical  veins. 

Pulmonic  Lesions.  —  As  compared  with  aortic 
lesions,  these  are  of  infrequent  occurrence,  and  they 
are  generally  congenital.  Lesions  giving  rise  to  a 
pulmonic  direct  murmur  may  be  localized  by  differ- 
entiating this  murmur  from  the  aortic  direct  mur- 
mur (vide  page  245).  It  is  to  be  considered  that  an 
inorganic  pulmonic  direct  murmur  is  not  infrequent. 
Pulmonic  regurgitant  lesions  can  only  be  diagnosti- 
cated by  determining  that  a  murmur  is  produced  at 


FATTY    DEGENERATION    OF    THE    HEART.      263 

the  pulmonic  and  not  at  the  aortic  orifice  (vide  page 
247). 

Fatty  Degeneration,  Myocarditis,  and  Softening  of  the 
Heart. — Fatty  degeneration  of  the  heart  is  not  rep- 
resented by  any  distinctive  signs,  but,  nevertheless, 
the  physical  diagnosis,  taking  into  account  the 
clinical  history,  may  be  quite  positive.  The  signs 
are  those  which  denote  persistent  muscular  weak- 
ness of  the  heart.  The  apex-beat,  if  appreciable,  is 
feeble.  The  intensity  of  the  heart-sounds  is  dimin- 
ished, and  especially  the  intensity  of  the  systolic 
sounds.  The  sound  of  impulsion  and  even  the 
mitral  valvular  sound  may  be  suppressed  over  the 
apex.  The  sound  of  impulsion  is  especially  im- 
paired or  lost,  the  systolic  sound  which  is  heard 
being  chiefly  or  exclusively  the  mitral  valvular 
sound.  This  sound  is  short  and  valvular,  in  quality 
like  the  diastolic  sound.  ISTow  these  evidences  of 
weakened  muscular  power  may  occur  when  the 
weakness  is  merely  functional,  and  when  the  heart 
is  enlarged  by  predominant  dilatation.  But  func- 
tional weakness  is  generally  transient,  and  is  suffi- 
ciently explained  by  the  existence  of  other  than 
eardiac  di.sease.  Enlargement  by  dilatation  is 
readily  determined  by  physical  signs,  [f  the  heart 
be  but  little,  or  not  at  all,  enlarged,  and  pathological 
conditions  adequate  to  explain  diminished  muscular 
power  irrespective  of  cardiac  disease  be  excluded, 
and  at  the  smir  time  the  signs  being  connected  with 
diagnostic  symptoms,  the  existence  of  fatty  degen- 
eration may  be  determined  with  much  confidence. 

Fatty    degeneration     may    COexisI     with    valvular 
lesions  and  enlargement  of  the  heart.     The  physical 


264  DISEASES    OF    THE    HEART. 

diagnosis  of  fatty  degeneration  under  these  circum- 
stances is  not  a  simple  problem.  A  probable  diag- 
nosis may  be  made  when  the  amount  of  enlargement 
seems  insufficient  to  account  for  the  signs  denoting; 
muscular  weakness  of  the  heart,  and  when  symptoms 
belonging  to  the  clinical  history  point  to  fatty  de- 
generation. 

Softening  of  the  muscular  structure  of  the  heart, 
occurring  in  myocarditis,  in  continued  fever,  and 
other  general  diseases,  is  denoted  by  the  same  signs 
which  are  embraced  in  the  physical  diagnosis  of 
fatty  degeneration,  the  most  marked  evidence  being 
notable  weakness  of  the  systolic  valvular  sounds, 
and  especially  weakness  or  suppression  of  the  sound 
of  impulsion. 

Endocarditis. — The  physical  diagnosis  of  endocar- 
ditis relates  especially  to  its  occurrence  in  connection 
with  articular  rheumatism.  The  diagnostic  sign  is 
a  mitral  systolic  non-regurgitant  murmur  (vide  page 
205).  The  presence  of  this  murmur,  however,  in  a 
case  of  rheumatism,  is  not  positive  proof  of  an  ex- 
isting endocarditis,  more  especially  if  the  patient 
have  previously  had  articular  rheumatism,  because 
an  endocarditis  developed  in  a  previous  attack  may 
have  left  a  permanent  murmur.  If  the  murmur  be 
a  mitral  regurgitant  murmur,  and  the  heart  be  en- 
larged, it  is  quite  certain  that  endocarditis  has  pre- 
viously occurred.  The  positive  proof  is  the  pro- 
duction of  the  murmur  during  an  attack  of  rheu- 
matism, when  previous  examinations  made  after  the 
commencement  of  the  rheumatic  attack,  had  shown 
that  there  was  no  mitral  murmur.  An  aortic  direct 
murmur,  in  cases  of  rheumatism,  is  not  evidence  of 


PERICARDITIS.  26<> 

endocarditis,  because  in  many  cases  of  rheumatism 
this  murmur  occurs  and  is  to  be  regarded  as  in- 
organic. 

In  the  variety  of  endocarditis  known  as  ulcerative, 
occurring  in  the  course  of  infectious  or  septic  dis- 
eases, and  sometimes  without  any  known  patholo- 
gical connection,  an  aortic  murmur  may  be  devel- 
oped, with  or  without  a  coexisting  mitral  murmur, 
owing  to  the  soft  masses  present  on  the  valves. 

Endocarditis  is  probably  of  frequent  occurrence  as 
secondary  to  mitral  and  aortic  valvular  lesions;  but, 
under  these  circumstances,  a  physical  diagnosis  is 
impracticable. 

Pericarditis. — The  physical  diagnosis  of  pericarditis 
in  the  first  stage,  that  is,  prior  to  the  effusion  of 
liquid,  is  to  be  based  on  a  pericardial  friction  mur- 
mur. Fortunately  for  diagnosis,  this  murmur  is 
uniformly  present.  Its  characters  as  contrasted  with 
endocardial  murmurs  have  been  stated  (vide  page 
214).  The  presence  of  a  pericardial  friction  mur- 
mur, in  connection  with  symptoms  denoting  peri- 
carditis, renders  the  diagnosis  quite  positive.  There 
is,  however,  one  liability  to  error.  In  some  cases  of 
pleurisy  or  pneumonia  with  pleuritic  inflammation, 
the  movements  of  the  heart  occasion  a  rubbing  to- 
gether of  the  roughened  pleural  surfaces,  and  in  this 
way  a  cardiac  pleural  friction  murmur  is  produced. 
This  may  be  single  or  double,  and  wbeii  double,  it 
simulates  the  murmur  produced  within  the  pericar- 
dial sac.  It  is  limited  to  the  border  <>f  the  heart,  and 
is  neither  accompanied  nor  followed  by  pericardial 
effusion.  Of  course,  the  error  of  mistaking  a  car- 
diac   pleural    friction    murmur     for    one     produced 


266  DISEASES    OF    THE    HEART. 

within  the  pericardium,  can  only  occur  when  pleurisy 
exists,  either  as  a  primary  affection  or  as  secondary 
to  pneumonia. 

In  the  second  stage  of  pericarditis,  that  is,  after 
the  effusion  of  liquid  has  taken  place,  the  pericardial 
friction  murmur  often,  but  not  always,  disappears. 
The  physical  diagnosis  in  this  stage  is  then  to  be 
based  on  the  signs  which  show  the  presence  of  a 
greater  or  less  quantity  of  liquid  within  the  pericar- 
dial sac.  The  signs  which  denote  pericardial  effu- 
sion, and  its  amount  have  been  stated  (vide  page 
220).  With  a  moderate  effusion,  the  apex  of  the 
heart  is  raised,  and  the  apex-beat  may  be  felt  in  the 
fourth  intercostal  space,  and  removed  to  the  left  of 
its  normal  situation.  With  considerable  or  large 
effusion,  the  apex-beat  is  lost,  and  the  sounds  of  the 
heart  are  feeble  and  distant.  The  sound  of  impul- 
sion is  lost,  leaving  the  mitral  aud  tricuspid  sounds, 
which  are  short  and  valvular  like  the  diastolic 
sounds. 

Increase  or  diminution  of  liquid  in  the  second 
stage  of  pericarditis  is  readily  determined  by  signs 
obtained  by  percussion  and  auscultation.  When  the 
quantity  is  much  diminished,  the  friction  murmur, 
if  it  have  been  suppressed,  returns,  and  persists 
until  the  pericardial  surfaces  become  agglutinated. 
Not  infrequently,  by  auscultating  when  the  body  of 
the  patient  is  inclined  forward,  a  friction  murmur 
may  be  heard,  notwithstanding  the  pericardial  sac 
contains  a  large  quantity  of  liquid. 

In  cases  of  chronic  pericarditis  with  very  large 
effusion,  dilatation  of  the  pericardial  sac  is  shown 
by  signs  obtained  by  percussion  and  auscultation. 


FUNCTIONAL    DISORDERS.  267 

There  is  no  apex  impulse,  the  heart-sounds  are 
feeble  and  distant,  the  systolic  sounds  being  short 
and  valvular,  and  the  praecordia  may  be  notably 
projecting. 

A  malignant  morbid  growth  tilling  the  pericardial 
sac  and  inclosing  within  it  the  heart,  may  give  rise 
to  all  the  signs  of  pericardial  effusion.  A  case  of 
this  kind,  in  a  young  subject,  has  fallen  under  my 
observation. 

With  reference  to  diagnosis,  the  etiological  rela- 
tions of  pericarditis  should  be  kept  in  mind.  These 
are  acute  articular  rheumatism,  Bright's  disease,  and 
either  pleurisy  or  pneumonia.  It  rarely  occurs  in 
other  connections,  and,  as  an  idiopathic  affection,  it 
is  extremely  rare. 

The  presence  of  air  and  liquid  within  the  pericar- 
dial sac  gives  rise  to  loud  splashing  sounds  which, 
occurring  when  respiration  is  suspended,  and  when 
pneumo-hydrothorax  is  excluded,  are  at  once  diag- 
nostic of  pneumo-hydropericardium. 

Functional  Disorders. — Of  the  varied  forms  of 
functional  disorder  of  the  heart,  some  are  rare,  and 
others  are  of  frequent  occurrence.  A  rare  form  is 
persistent  frequency  of  the  heart's  action,  the  pulse 
being  from  100  to  120  or  more  per  minute,  for 
weeks,  months,  and  even  years.  This  form  <»t'  dis- 
order exists  in  the  affection  known  as  exophthalmic 
goitre,  Graves's  or  Basedow's  disease.  It  occurs, 
also,  without  being  associated  with  either  promi- 
nence <>f  the  eyes  or  enlargement  <>f  the  thyroid 
body.  In  a  rare  form,  the  opposite  of  this,  the  ac- 
tion of  the  heart  is  abnormally  infrequent,  the  pulse 
falling  to  50,  10,  i".  or  less,  per  minute,  the  infre- 


268  DISEASES    OF    THE    HEART. 

quency  not  being  an  idiosyncrasy,  either  congenital 
or  acquired,  and  continuing  for  a  limited  period. 
The  occurrence  with  eveiw  alternate  revolution  of 
the  heart  of  a  ventricular  systole  so  feeble  as  not  to 
be  represented  by  a  radial  pulse,  is  another  rare 
form,  and  another  is  a  want  of  synchronism  in  either 
the  contraction  of  the  two  ventricles,  or  of  the  recoil 
of  the  coats  of  the  aorta  and  the  pulmonic  artery, 
giving  rise  to  reduplication  of  heart-sounds  {vide 
page  226).  In  the  more  common  forms,  the  disorder 
occurs  in  paroxysms  which  are  variable  in  duration 
and  in  the  frequency  of  their  occurrence,  the  heart, 
in  the  paroxysms,  beating  irregularly,  and  often 
with  intermissions,  the  action  in  some  instances 
being  violent  and  in  other  instances  feeble  or  flut- 
tering. These  common  forms  are  embraced  under 
the  name  palpitation. 

As  regards  the  physical  diagnosis,  all  the  forms  of 
disorder  are  in  the  same  category;  in  all  the  func- 
tional character  of  the  affection  is  determined  by 
exclusion,  inflammatory  affections  and  lesions  being 
excluded  by  the  absence  of  their  diagnostic  signs. 
In  whatever  way  the  action  of  the  heart  is  disturbed, 
however  great  may  be  the  disturbance,  and  let  it  be 
attended  with  ever  so  much  distress  or  anxiety,  if 
physical  exploration  furnish  no  evidence  of  endo- 
carditis, pericarditis,  valvular  lesions,  enlargement 
of  the  heart,  fatty  degeneration,  or  heart-clot,  the 
affection  is  to  be  considered  as  functional.  If  purely 
functional,  the  affection  is  unattended  by  danger, 
and  is  generally  remediable,  at  least  in  the  common 
forms.  Hence,  the  very  great  importance  of  a  posi- 
tive diagnosis. 


FUNCTIONAL    DISORDERS.  269 

In  one  point  of  view,  the  physical  diagnosis  in 
functional  disorders  may  be  said  to  rest,  not  on 
negative,  but  on  positive  evidence.  Percussion  and 
auscultation  afford  the  means,  not  only  of  excluding 
inflammatory  affections  and  lesions,  but  of  demon- 
strating the  fact  that  the  organ  is  sound,  at  least  as 
regards  freedom  from  ordinary  lesions.  That  its 
size  is  normal,  is  shown  by  the  normal  situation  of 
the  apex-beat,  of  the  lateral  boundaries  of  the  prse- 
cordia,  and  of  the  area  of  the  superficial  cardiac 
space.  That  the  valves  are  unaffected,  is  shown  by 
the  normal  characters  of  the  heart-sounds.  These 
positive  facts,  taken  in  connection  with  the  absence 
of  morbid  signs,  render  the  diagnosis  certain.  More- 
over, the  evidence,  positive  and  negative,  is  readily 
and  quickly  obtained.  Indeed,  the  time  required 
for  reaching  a  conclusion  is  so  brief,  that  it  is  often 
politic  to  prolong  unnecessariry  the  examination  in 
order  that  a  positive  assurance  of  the  soundness  of 
the  organ  may  have  in  the  mind  of  the  patient  the 
weight  which  is  desirable  in  order  to  secure  relief 
from  anxiety  and  apprehension. 

Functional  disorders  are  not  infrequently  asso- 
ciated with  lesions  with  which  they  have  no  essential 
pathological  connection.  A  patient  with  lesions 
which  are  either  innocuous  or  attended  with  little, 
if  any,  inconvenience,  may  suffer  from  disturbance 
of  the  action  of  the  heart  produced  by  causes  which 
are  wholly  Independent  of  the  lesions.  There  is  a 
liability,  in  these  cases,  to  the  error  of  attributing 
the  disorders  to  the  lesions,  and  thus  forming  an  ex- 
aggerated estimate  of  the  importance  of  the  Latter. 
To  decide  how  much  of  the  disturbed  action  of  the 


270  DISEASES    OF    THE    HEART. 

heart  is  due  to  a  superadded  functional  affection,  is 
not  as  easy  as  to  determine  that  lesions  do  not  exist. 
The  decision  must  be  based  on  the  character,  degree, 
or  extent  of  the  lesions,  as  evidenced  by  the  physical 
signs.  In  this  connection  may  be  stated  a  practical 
maxim  which  it  is  well  to  bear  in  mind  whether 
functional  disorders  exist  or  not,  namely,  valvular 
lesions  rarely  give  rise  to  much  inconvenience  until 
they  have  led  to  enlargement  of  the  heart ;  and  en- 
largement, either  with  or  without  valvular  lesions, 
as  a  rule,  does  not  lead  to  the  serious  effects  which 
are  characteristic  of  cardiac  disease,  so  long  as  the 
enlargement  is  due  to  predominant  hypertrophy  and 
not  to  dilatation. 

Thoracic  Aneurism. 

The  physical  conditions  incident  to  thoracic  aneu- 
rism which  are  concerned  in  the  production  of  signs, 
are,  the  presence  of  a  tumor  within  the  chest,  of 
variable  size,  formed  by  the  aneurismal  sac ;  the 
passage  of  blood  into  the  sac  with  each  ventricular 
systole,  and  the  expulsion  of  blood  in  the  diastole  by 
the  recoil  of  the  coats  of  the  aneurism ;  the  size  of 
the  opening  into  the  sac  as  affecting  the  quantity  of 
blood  which  it  receives  with  each  systole ;  the  quan- 
tity of  stratified  fibrin  which  the  sac  contains ;  the 
point  of  connection  with  the  aorta  of  the  aneurismal 
tumor,  and  the  direction  from  this  point  in  which 
the  tumor  extends,  together  with  its  relations  to  the 
lungs,  the  trachea,  the  primary  bronchi,  the  intra- 
thoracic veins,  the  oesophagus,  the  recurrent  laryngeal 


THORACIC    ANEURISM.  271 

nerve,  the  sympathetic  nerve,  and  either  the  innom- 
inate or  subclavian  artery. 

With  reference  to  diagnosis,  it  is  well  to  bear  in 
mind  that,  in  the  great  majority  of  cases,  an  aortic 
aneurism  is  connected  with  either  the  ascending 
portion,  or  the  junction  of  the  ascending  and  the 
transverse  portion  of  the  arch,  and  that  the  tumor 
generally  extends  to  the  right  in  a  lateral  or  antero- 
lateral direction.  The  physical  diagnosis  is  more 
easily  made  when  the  aneurismal  tumor  is  thus  con- 
nected. The  signs  are  less  available  if  the  aneurism 
arise  from  the  transverse  or  descending  aorta,  and 
especially  if  the  tumor  extends  in  a  direction  down- 
ward or  backward. 

An  aneurismal  tumor  which  has  made  its  way 
through  the  walls  of  the  chest,  or  which,  without 
perforation,  causes  a  circumscribed  bulging  obvious 
to  the  eye  and  touch,  presents  the  following  diag- 
nostic signs :  An  impulse  is  seen  and  felt  which  is 
synchronous  with  the  ventricular  systole.  The  force 
of  the  impulse  is  variable,  depending,  aside  from  the 
force  with  which  the  left  ventricle  contracts,  upon 
the  size  of  the  orifice  between  the  sac  and  the  artery, 
and  the  quantity  of  fibrin  which  the  sac  contains.  A 
vibration  or  thrill  with  each  impulse  is  sometimes  a 
marked  sign,  but  is  often  wanting.  Frequently,  but 
by  no  means  constantly,  a  systolic  murmur  is  heard 
over  the  tumor,  and  there  may  be  also  a  diastolic 
murmur  produced  by  the  passage  of  blood  from  the 
sac.  The  heart-sounds  are  transmitted  to  the  tumor 
with  more  or  Less  increased  intensity.  There  is 
notable  dulness  on  percussion  over  an  area  corre- 
sponding to  the  space  within  the  chest  which  the 


272  DISEASES    OF    THE    HEART. 

tumor  occupies.  If  the  tumor  be  of  considerable 
size,  it  may  produce  condensation  of  lung  around  it; 
the  area  of  dulness  on  percussion  will  be  in  this  way 
extended  beyond  the  limits  of  the  tumor.  Under 
these  circumstances,  bronchial  respiration  and  bron- 
chophony may  be  produced.  If  the  aneurismal  sac 
be  beneath  the  integument,  there  may  be  to  the 
touch  a  sense  of  fluctuation. 

With  the  foregoing  signs,  the  physical  diagnosis 
scarcely  admits  of  doubt.  Some  of  the  signs  may  be 
produced  by  a  tumor,  not  aneurismal,  so  situated  as 
to  receive  and  conduct  the  aortic  impulse.  The 
chances  of  a  tumor  being  so  situated  as  to  simulate 
the  signs  of  an  aneurism  are  few.  I  have  met  with 
a  case  of  empyema  in  which  perforation  of  the  chest 
took  place  in  the  second  intercostal  space  on  the 
right  side  of  the  sternum,  giving  rise  in  this  situation 
to  a  fluctuating  tumor  which  had  a  strong  pulsation. 
On  a  superficial  examination  the  case  seemed  clearly 
one  of  aneurism ;  but  an  examination  of  the  chest 
showed  the  right  pleural  cavity  to  be  filled  with 
liquid,  and  a  puncture  in  the  axillary  region  gave 
exit  to  a  large  quantity  of  pus,  the  pulsating  tumor 
disappearing  after  a  certain  quantity  of  the  purulent 
liquid  had  escaped.  I  have  met  with  a  similar  pul- 
sating tumor,  incident  to  empyema,  on  the  posterior 
aspect  of  the  chest. 

When,  from  its  small  size  or  its  situation,  an 
aneurismal  tumor  does  not  come  into  contact  with 
the  thoracic  wall,  and  when  it  is  situated  beneath 
the  sternum,  signs  obtained  by  palpation  and  inspec- 
tion being  absent,  the  physical  diagnosis  is  less  easy. 
Important  signs  are,  dulness  within  a  circumscribed 


THORACIC    ANEURISM.  273 

-pace  situated  in  the  course  of  the  aorta;  an  abnor- 
mal transmission  of  the  heart-sounds  within  this 
space,  and  the  presence  of  murmurs.  These  signs 
are  not  always  available,  and  when  present  they  are 
not  sufficient  for  a  positive  diagnosis.  Other  physi- 
cal evidence  and  the  presence  of  certain  symptoms 
render  the  existence  of  aneurism  highly  probable 
either  with  or  without  the  foregoing  signs.  If  an 
aneurismal  tumor  press  upon  the  trachea,  it  occa- 
sions a  tracheal  rale,  or  stridor,  together  with 
weakness  of  the  respiratory  murmur  on  both  sides 
of  the  chest.  If  the  tumor  press  upon  a  primary 
bronchus,  it  occasions  diminished  or  suppressed  re- 
spiratory murmur  on  one  side,  and  increased  respira- 
tory murmur  on  the  other  side  of  the  chest.  These 
physical  signs  should  always  lead  to  a  suspicion  of 
aneurism  in  a  person  forty  years  of  age.  Symptoms 
which  should  excite  this  suspicion  and  lead  to  careful 
physical  exploration  for  the  physical  signs  of  aneu- 
rism, are  dyspnoea  from  spasm  or  paralysis  of  the 
muscles  of  the  glottis,  and  aphonia  or  impairment 
of  the  voice  without  evidence  of  laryngitis,  these 
symptoms  denoting  either  excitation  or  pressure  of 
the  recurrent  laryngeal  nerve;  dysphagia  from  pres- 
sure upon  the  oesophagus;  congestion  of  the  face 
Deck,  and  upper  extremities  from  obstruction  of  the 
vena  cava  or  the  veme  innominate;  inequality  of 
the  radial,  carotid,  and  subclavian  pulsation  on  the 
two  sides,  or  the  al>s>  11  e  of  pulsation  en  one  side, 
and  contraction  of  one  of  the  pupils.  These  symp- 
toms not  only  render  probable  the  existence  of 
aneurism,  but   indicate  it<  situation  a-  regards  the 


274  DISEASES    OF    THE    HEART. 

aorta  and  the  direction  in  which  the  aneurismal 
tumor  extends. 

An  aneurism  may  be  suspected  when,  owing  to 
shrinkage  of  the  lung,  or  deformity  of  the  chest, 
either  the  aorta  or  the  pulmonary  artery  just  above 
the  heart  is  removed  laterally  from  its  normal 
situation  or  brought  into  contact  with  the  walls  of 
the  chest  in  the  second  intercostal  space,  so  as  to 
give  rise  to  an  appreciable  impulse.  A  murmur 
may  also  be  present  at  the  point  of  impulse.  An 
error  of  diagnosis  under  these  circumstances  is 
avoided  by  finding  an  adequate  explanation  of  the 
signs  just  noted,  and  by  the  absence  of  other  signs 
and  of  symptoms  which  are  diagnostic  of  aneurism. 

In  conclusion,  an  aortic  murmur,  however  intense 
or  rough,  is  never  evidence  of  aortic  aneurism,  and, 
on  the  other  hand,  the  absence  of  murmur  is  by  no 
means  sufficient  for  the  exclusion  of  aneurism. 


INDEX. 


ABSCESS  of  lung,  23,  25,  185 
Adventitious       respiratory 

sounds  or  rales.  122 
cavernous,  134 
classification  of,  122 
crepitant,  23,  131,  171 
dry  bronchial,  129,  158, 

163 
gurgling,  134 
indeterminate,  139 
laryngeal  and  tracheal, 

122 
metallic   tinkling,   137, 

152 
moist     bronchial,    123, 

159,  161 
pleural  or  friction,  21, 

135,  171,  265 
sibilant   and   sonorous, 

129,  163 
splashing  or  succussion, 

135,  138,  179,  267 
subcrepitant,   124,   125, 
126 
dSgophony,  143,  173 
Air  in  pleural  space,  21 
Amphoric  resonance,  71 

conditions  causing,  72 
respiration,  115 
voice,  149 
whisper,  149 
A  nalysis  of  Bounds,  33 
Aneurism,  thoracic,  25,  27,  260, 

270 
A  irta  and  pulmonary  artery,  il- 
lations of,  to  chest-walls,  207 
Aortic  direct  murmur,  289,  260 
diastolic       non-regurgitant 
murmur.  241,  260 

lesions,  diagnosis  of,  260 
regurgitant  murmur, 2 1 1 ,260 

A  pex-b<  al  of  heart,  modification 
of,  201,  205,  217,261       i 

A  poplezy,  pulmonary,  66,  I B6 


Artery,    pulmonic,    and    aorta, 
relation  of,  to  walls  of  chest,  207 
Asthma,  24,  130,  162 
Atrophy,  senile,  of  lungs,  165, 

168 
Auscultation,  definition  of,  14,  74 

in  disease,  98 

in  health,  75,  81 

mediate  and  immediate,  76 

position  for,  80 

rules  in  practice  of,  79 

B AS KDOW'S  disease,  267 
Blood  currents,  aortic,  230, 
231 
direct,  229,232 
mitral,  229 
pulmonic,  231 
regurgitant,  229 
relation    of,    to     heart 

sounds,  230 
tricuspid,  231 
Bread,   use  of,    to  imitate  pul- 
monary signs,  47,  70,  71 
Bronchi,  obstruction  of,  24,  27 
Bronchial  rales,  dry,  129,158,163 
moist,  123",  159,  161 
respiration,  105 
causes,  106 
whisper,  increased,  14ti 
normal,  95 
Bronchitis  seated  in  large  bron- 
chial tubes,  28,  157 
in  small  bronchial  tubes 
(capillary),  24,  159 

Broncho-cavernous    respiration. 

ill 
Bronchophony,  1  10 

whispering,  142,  1 16 
Broncborrhagia,  28 
Bronchorrhoea,  28,  L25 
Broncho-vesicular     respiration. 

108 
Bruit  de  diabU,  240 


276 


INDEX 


CAPILLARY  bronchitis,  159 
Carcinoma  of  lung,  22,  25, 
190 
Cardiac    space,   superficial    and 

deep,  52,  168,  204,  206 
Cavernous  rale,  134 
respiration,  111 

imitation  of,  113 
Cavities,  pulmonary,  25,  27,  194, 

200 
Chest,  anatomy  and  physiologv 
of,  16,  207 
regional  divisions  of,  35,  50, 
86 
Cirrhosis  of  lung,  201 
Clicking  rale,  131 
Cogged-wheel  respiration,  120 
Collapse  of  lung,  22,  159 
Conditions,  morbid  physical,  in- 
cident to  different  dis- 
eases of  the  respiratory 
system,  20,  155 
summary  of,  26 
physical,  of  the  heart  in  dis- 
ease, 203,  215 
in  health,  203,  204 
represented     by     amphoric 
resonance,  72 
by  cracked-metal  reso- 
nance, 73 
by  dulness,  66 
by  flatness   on   percus- 
sion, 64 
by      tympanitic     reso- 
nance, 68 
by    vesiculo  tympanitic 
resonance,  70 
Congestion,  hypostatic,  of  lungs, 

oedema  in,  189 
Coughing,  signs  obtained  by,  152 
Cracked-metal  resonance,  73 

imitation  of,  73 
Crepitant  rale,  23,  131,  171 

DEATH-RATTLES,  122 
Diaphragmatic  hernia,  202 
Diseases  of  the  respiratory  sys- 
tem, physical  conditions  inci- 
dent to,  20.  154 
Dulness,  66 

conditions  causing,  06 
hepatic,  53,  56 


Dulness,  tympanitic,  68,  200 
Duration  of  sounds,  33 
Dysphagia,    in    thoracic    aneu- 
rism, 273 

ECHO,  amphoric,  149 
Emphysema,    diagnosis   of, 
169 
pulmonary  or  vesicular, 
22,  27,*70,  117,  160, 
161,  163,  164 
interlobular,  23 
rhythm  of  respirations 
in,  167 
Empyema,  21,  169,  175 

pulsating,  176 
Endocardial  murmurs,  228,  248 
Endocarditis,  diagnosis  of,  264 
Exocardial  murmur,  228,  248 
Expiratory  sound,  prolonged.  118 
Exploration,  physical,  different 

methods  of,  13 
Exudation  in  air-vesicles,  23,  27 

FISSURES,  interlobar,  18,  41, 
42 
Flatness,  64 

conditions  causing,  64 
hepatic,  53,  56 
Fremitus,  diminished,  151 
increased,  143,  146 
in  different  regions,  92 
normal,  vocal,  90 
suppressed,  151 
Friction     murmur,     pericardial, 
229 
pleuritic,  21,  135,  171,  265 

GANGRENE,  pulmonary,  22, 
25,  187 
Glottis,  oedema  of,  156 
paralysis  of,  155,  273 
spasm  of,  155 
Goitre,  exophthalmic,  267 
Graves's  disease,  267 
Gurgling  rale,  134 

HEART,  abnormal  impulses  of, 
217 
anatomical  relations  of,  203 
apex  beat  of,  20,  204,  205, 
217,  251,  252,  254 


INDEX. 


277 


Heart,   diagnosis  of  diseases  of, 
251 
dilatation  of,  217 
enlargement  of,  215,  2-31 
fattv  degeneration  and  soft- 
ening of,  218,  203 
first   sound    of,   intensified, 
222 
weakened,  222 
functional  disorders  of,  267 
hypertrophy  of,  217 
hypertrophy  and  dilatation 
of,  260 
Bigns  of,  251,  25"),  256 
inflammation  of,  263,  264 
murmurs  of,  203,  208,  227, 

2  4  \> 
normal,  251 
palpitation  of,  268 
physical    conditions   of,   hi 
disease,  203,  215 
in  health,  203,204 
second  sound,  aortic,  weak- 
ened, 224 
pulmonic,      weak- 
ened, 224 
softening  of,  203 
sounds  of,  203.  208 

abnormal  modifications 
of,  221,224 
transmission  of,  in 
phthisis,  109 
five  in  number,  214 
mechanism  of,  210,  21 1 
mitral  systolic,  213,  214, 

225 
reduplication    of,    226, 

208 
tricuspid    ~vstolic,  213, 
21  1,  2-5  ' 
valvular  [<  219,  267 

aortic,  260 
mitral,  2~>7 
pulmonic,  262 
tricuspid,  201 
Hemorrhagic   infarctus,  22.   66, 

186 
Hernia,  diaphragmatic,  26,  27, 

2(12 
Hum,  venous,  2 1<i 
Hydatids  of  lung,  22 
Hydrothorax,  21,  169,  \:<; 


INDETERMINATE  rales,  139 
1     Infarctus,   hemorrhagic.   22. 

65,  186 
Inspiratory  sound  shortened,  117 
Intensity  of  normal  and  abnor- 
mal sounds,  differences  of,  28, 
29,  46,  68 
Interrupted  respiration,  120 
Interstitial  pneumonia,  2i'l 

JERKING  respiration,  120 


LARYNGEAL    and    tracheal 
respiration,  82 
rales,  122 
voice,  89 
Laryngismus  stridulus,  L55 
Larynx,  foreign  bodies  in,  156 
and   trachea,    affections   of, 

27,  155,  156 
tumors  of,  150 
ulcers  of,  156 
Lesions,  valvular,  of  heart,  219, 
1 
diagnosis  of,  257 
Liquid,  in  chest,  21,  23,  26,  64 
Liver,  dulness  over,  53,  56 

flatness  over,  53,  56 
Lobular  pneumonia,  22,  159,  101 
Lobules,  pulmonarv,  collapse  of, 

22,  159 
Lung,  solidification   of,   22,  27, 
34,  108,  145,  146 

METALLIC  tinkling,  135,  187, 
152, 179 
Mitral  lesions,  diagnosis  of,  267 
Mitral  murmurs,  direct,  282 
diastolic. 
regurgitant,  286 
presystolic,  282 
systolic  non -regurgitant   or 
intra-ventricular,  286 
Murmur,  aortic  direct,  239,  242, 
2C:,  217 

aortic  prediastolic,  241 
cardiac,  208,  208,  220,  227. 

282,  248 
cardiac  pleural, 
diastolic  or  non-regurgitaut, 

211 


24 


278 


INDEX 


.Murmur,  endocardial,  228,  248 
coexisting,  242 
exocardial,  228,  248 
mitral  diastolic,  236,  257 
presystolic,  232,  257 
mechanism  of,  232 
without  mitral  lesions, 

233,  235,  257 
limits  of,  234 
thrill  with,  235 
mitral  direct,  232 

regurgitant,  23G,  257 
mitral  systolic,  non-regurgi- 
tant,  or  intra-ventri- 
cular,  236,  251 
causation,  237,  258 
normal  vesicular,  84 

in  the  different  regions, 
86 
pericardial  or  friction,  228, 

248 
pulmonic  direct,  245 
regurgitant,  247 
regurgitant,  241 
tricuspid  direct,  244 
regurgitant,  244 
vesicular  diminished,  101 
causes,  103 
increased,  100 
suppressed,  103 
Murmurs,  endocardial,  228,  231 
exocardial,  228,  248 
facts  of  importance  relating 

to,  247 
groups  of,  227 
hsemic,  227 

organic  and  inorganic,  227 
Myocarditis,  263 


(E 


.  DEMA,  pulmonary,  23,  27, 
h    65,  133,  161,  188 
Organs,  respiratory,  anatomy  and 
physiology  of,  16 

PALPITATION,  cardiac,  268 
Pectoriloquy,  148 
Percussion,   analysis   of   sounds 
in,  46 
definition  of,  14 
in  health,  44 
in  disease,  63 
instruments  for,  44 


Percussion,    modes  of  perform- 
ing, 45 
objects  of,  46 
position  for,  60,  61 
respiratory,  59 
rules  in  practice  of,  60 
sense  of  resistance  in,  74 
signs   of    disease    furnished 
by,  63 
Percussors,  45 

Pericardial  or  friction  murmur, 
228,  248,  265 
sac,  liquid  within,  220 
surfaces,  roughness  of,  220 
Pericarditis,  chronic,  266 

diagnosis  of,  265 
Phthisis,  22,  23,  25,  112,  193 
advanced,  194,  200 
differential  diagnosis  of,  199 
fibroid,  201 

groups  of  cases  in,  193 
incipient,  193,  196,  198 
moderate,  194 
signs,   direct  and  accessory 
of,  195 
Pitch  of  normal  and  abnormal 

sounds,  28,  29,  46 
Pleural  rales,  21,  135,  171,  265 
Pleurisy,  acute  and  chronic,  21, 
26,  35,  169 
signs  of  first  stage  of,  171 
friction  sound  in,  171 
signs    of   second    stage   of, 
171 
horizontal  and  S-shaped 
lines  in,  172 
Pleurisy,  chronic,  signs  of,  174 
Pleuro-pneumonia,  180 
Pleximeters,  44 

Pneumonia,  acute  lobar,  23,  179 
circumscribed,  186 
crepitant  rale  in,  180,  184 
embolic,  22,  186 
interstitial,  22,  201 
lobular,  22,  159,  161 
signs  of  abscess  in,  185 
signs  in  first  stage,  180 
signs  of  purulent  infiltration 

in,  185 
signs  in  second  stage,  181 
signs  in  third  stage,  183 
Pneumo-hydropericardium,  267 


INDEX 


279 


Pneumo-hydrothorax,21,  26,  177 
amphoric  voice  in,  179 
metallic  tinkle  in,  179 

Pneumo-pyothorax,  177 

Pneumorrhagia,  23,  187 

Pneumothorax,   21,  27,  11:!,  177 

Praecordia,  204,  216 

Pulmonary  apoplexy,  18G 
gangrene,  22,  25,  187 
oedema,  23,  27,  65,  133,  161, 
188 

Pulmonic  direct  murmur,  245 
lesions,  diagnosis  of,  262 
regurgitant    murmur,    247, 
262 

Pupils,  inequality  of,  in  thoracic 
aneurism,  273 

Pyothorax,  21 


Q 


UALITY  of  normal  and  ab- 
normal sounds,  28,  30,  46 
terms  denoting,  32 


RALE,  cavernous  or  gurgling, 
134 
crepitant   or   vesicular,   23, 

131 
indeterminate,  139 
metallic  tinkling,  137,  152 
Bplashing  or  succussion,  135, 

138,  179,  267 
Kales,  122 

line    bubbling  or  subcrepi- 

tant,  124,  125,  126 
classification  of,  122 
dry  bronchial,  129,  158,  163 
laryngeal  and  tracheal,  122 
moist    bronchial,    12:1,    169, 

161 
pitch  of,  24 
pleural   or  friction.  21,  186, 

171,  266 
tracheal,  2  1,  122 
sibilant   and   sonorous,    129, 

163 

Regions,    anatomical     relatione 
of,  40 
division  of  chest  into,  B6 
i  ions  of  cheat  correspond- 
ing to,  86,  60,  mi; 
Resistance,  sense  of,  in  percus- 
sion, 74 


Resonance,   absence  of,  or  flat- 
ness, 64 
amphoric,  71 
cracked  metal,  73 
diminished,  or  dulness,  66 
disparity    of,    on    the    two 

sides,  57 
in  different  regions,  50 
normal,   vesicular,  on    per- 
cussion, 47 
vocal,  over  larynx  and 
trachea,  89 
over  chest,  90 
standard  for,  66 
tympanitic,  48,  49,  68 
variations    in    different   re- 
gions of  chest,  50 
vesiculo-tympanitic,  70,  166 
vocal,  diminished,  150 
increased,  143 
causes  of,  144 
Respiration,  abnormal  modifica- 
tions of,  99 
amphoric,  115 

imitation  of,  116 
bronchial  or  tubular, 105,272 
broncho-cavernous,  114 
broncho-vesicular,  108 
cavernous,  111 
diminished,  101,156,161,166 
harsh,  108 
indeterminate,  108 
in  different  regions,  86 
interrupted,  120 
metamorphosing,  114 
normal,  laryngeal,  and  tra- 
cheal, 82 
vesicular  murmur  of,  84 
puerile,  100 
rude,  108 
•  supplementary,  100 
suppressed,  103 
vesicular     murmur    of,    in- 
creased, 100 
vesiculo-ca^  ernous,  1 1"> 
Respiratory     organs,    anatomy, 
physiology  of,  16 
physical  conditions  in- 
cident to  diseases  <>f, 
20,  26, 
Rhythm,  respiratory, 
in  emphysema,  167 


280 


INDEX. 


QIGNS,  14 

tj     by  percussion  in  disease,  63 
in  health,  44 
healthy    and    morbid,    dis- 
tinctive characters  of,  14, 
27 
object  of,  15 

obtained  by  coughing,  152 
physical,  definition  of,  14 
respiratory,   in  disease,  99, 
103  et  seq. 
classification  of,  99 
in  health,  75 
significance  of,  34 

as  representing  physical 
conditions,  34 
vocal,  in  health,  89 
of  disease,  140 
Softening  of  the  heart,  2G3 
Sounds,  differences  of  intensity 
in,  28,  29 
in  pitch,  29 
in  quality,  30 
normal  and  abnormal,  14,  99 
rhythm  of,  33 
Spleen,  54 
Splashing  or  suecussion  sounds, 

135,  138,  179,  267 
Stethoscope,  advantages  of,  76 
binaural,  76 
Allison's,  79 
Stomach,  54 

THOKACIC  aneurism,  270 
diagnosis   of,  from  em- 
pyema, 272 
Thrill,    with   mitral   presystolic 
murmurs,  235 
with  thoracic  aneurism,  271 
Thymus  gland,  55 
Tinkling,  metallic,  135,  152,  1-79 
Trachea,  affections  of,  27,  155 
Tracheal  respiration,  82 
Tricuspid,  direct  murmur,  244, 
261 
lesions,  diagnosis  of,  261 
regurgitant    murmur,   244, 

262 
safety-valve  function  of,  231 


Tuberculosis,  acute,  161,  192 
Tubular  respiration,  105 
Tumor  within  the  chest,  26,  27, 

65,  199,  267 
Tussive  signs,  152 

significance  of,  153 
Tympanitic  dulness,  68,  200 
resonance,  40,  48,  68 

conditions  causing,  68 

VALVULAR  cardiac  lesions, 
219,  257 
aortic,  260 
mitral,  257 
pulmonic,  262 
tricuspid,  261 
j  Venous  hum,  240 
|  Vesicular  rale,  131 

resonance,  normal,  47,  48 
Vesiculocavernous     respiration, 

115 
Vesiculo-tympanitic    resonance, 
70,  165 
conditions  causing,  70 
Vocal   fremitus,   diminished   or 
suppressed,  151 
normal,  90,  92 
increased,  143,  146 
resonance,   diminished   and 
suppressed,  150 
normal,  89,  90 

in  different  regions, 
92 
increased,  142,  144 
signs  of  disease,  140 
Voice,  abnormal,  140 
amphoric,  149 
laryngeal  and  tracheal,  89 
normal,  90,  92 

WAVY  respiration,  120,  196 
"Whisper,  amphoric,  149 
bronchial, increased, 146 
cavernous,  147 
in  different  regions,' 97 
laryngeal  or  tracheal,  95 
normal  bronchial,  95 
Whispering  pectoriloquy,  148 




DEMC 


DATE  DUE 

DEMCO  38-296 

RC76.3 

[Flint 

(Manual   of  auscL.1  +  <.4, 


F64 
188f 
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